Provider Demographics
NPI:1639226202
Name:HETHUMUNI, STEPHANEE SIRIMAUO (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANEE
Middle Name:SIRIMAUO
Last Name:HETHUMUNI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 GLEN OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-1053
Mailing Address - Country:US
Mailing Address - Phone:626-683-8301
Mailing Address - Fax:
Practice Address - Street 1:101 E BEVERLY BLVD
Practice Address - Street 2:404
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4300
Practice Address - Country:US
Practice Address - Phone:323-722-6861
Practice Address - Fax:323-722-0158
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33432302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization