Provider Demographics
NPI:1861634792
Name:KANJANAVAIKOON, PAIYARUT (MD)
Entity Type:Individual
Prefix:DR
First Name:PAIYARUT
Middle Name:
Last Name:KANJANAVAIKOON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:KANJANAVAIKOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1300 CRANE ST
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4260
Mailing Address - Country:US
Mailing Address - Phone:650-498-6632
Mailing Address - Fax:
Practice Address - Street 1:321 MIDDLEFIELD RD
Practice Address - Street 2:SUITE 165
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-3500
Practice Address - Country:US
Practice Address - Phone:650-498-6675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.204324207V00000X
CAA126761207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1921734Medicaid