Provider Demographics
NPI:1639246580
Name:SJAUWFOEKLOY, DESMOND ADRIAN (MD)
Entity Type:Individual
Prefix:
First Name:DESMOND
Middle Name:ADRIAN
Last Name:SJAUWFOEKLOY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24422 AVENIDA DE LA CARLOTA
Mailing Address - Street 2:STE 275
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3669
Mailing Address - Country:US
Mailing Address - Phone:714-639-9401
Mailing Address - Fax:714-919-8804
Practice Address - Street 1:1010 W LA VETA AVE STE 750
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4312
Practice Address - Country:US
Practice Address - Phone:714-639-9401
Practice Address - Fax:714-919-8804
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA74658207RP1001X, 207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACG5665OtherRAILROAD MEDICARE - GROUP PIN
CAGR0003350OtherMEDICAID - GROUP PROVIDER
CAW1514OtherMEDICARE PTAN - TYPE 2
CA1912919804Medicaid
CAP00986419OtherRAILROAD MEDICARE INDIVIDUAL PIN
1912919804OtherNPI - TYPE 2
CAA74658OtherSTATE MEDICAL LICENSE
CAA74658OtherSTATE MEDICAL LICENSE
CAW1514OtherMEDICARE PTAN - TYPE 2