Provider Demographics
NPI:1922032952
Name:BHAVABHUTANON, LUKCHAI (DO)
Entity Type:Individual
Prefix:
First Name:LUKCHAI
Middle Name:
Last Name:BHAVABHUTANON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 S ATLANTIC BLVD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-4700
Mailing Address - Country:US
Mailing Address - Phone:626-300-8424
Mailing Address - Fax:
Practice Address - Street 1:880 S ATLANTIC BLVD
Practice Address - Street 2:SUITE 307
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-4700
Practice Address - Country:US
Practice Address - Phone:626-300-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7134207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH07749Medicare UPIN
CACB230624Medicare PIN