Provider Demographics
NPI:1932214517
Name:JIRASUT, DUMRONG (MD)
Entity Type:Individual
Prefix:MR
First Name:DUMRONG
Middle Name:
Last Name:JIRASUT
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 1:75 W MARCH LANE
Mailing Address - Street 2:SUITE H
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5729
Mailing Address - Country:US
Mailing Address - Phone:209-477-4485
Mailing Address - Fax:209-477-4487
Practice Address - Street 1:75 W MARCH LANE
Practice Address - Street 2:SUITE H
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5729
Practice Address - Country:US
Practice Address - Phone:209-477-4485
Practice Address - Fax:209-477-4487
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41741208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A417410Medicaid
A88577Medicare UPIN
CA00A417410Medicaid