Provider Demographics
NPI:1689961468
Name:SIRICHOTIRATANA, MELISSA PAM (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:PAM
Last Name:SIRICHOTIRATANA
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 1:3629 VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4522
Mailing Address - Country:US
Mailing Address - Phone:760-757-7546
Mailing Address - Fax:760-828-9138
Practice Address - Street 1:3629 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4522
Practice Address - Country:US
Practice Address - Phone:760-757-7546
Practice Address - Fax:760-828-9138
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA137981207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology