Provider Demographics
NPI:1760493126
Name:JUTABHA, CHIAKI MIURA (MD)
Entity Type:Individual
Prefix:
First Name:CHIAKI
Middle Name:MIURA
Last Name:JUTABHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-829-9935
Mailing Address - Fax:310-829-1077
Practice Address - Street 1:2501 N SEPULVEDA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2722
Practice Address - Country:US
Practice Address - Phone:310-546-8702
Practice Address - Fax:310-545-5310
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64833208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A648330Medicaid
CAG98146Medicare UPIN
CA00A648330Medicaid