Provider Demographics
NPI:1043337173
Name:BUDIHARDJO, IMAWATI (MD, PHD)
Entity type:Individual
Prefix:
First Name:IMAWATI
Middle Name:
Last Name:BUDIHARDJO
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3855 HEALTH SCIENCES DRIVE
Mailing Address - Street 2:ROOM 2016
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-0698
Mailing Address - Country:US
Mailing Address - Phone:858-822-7916
Mailing Address - Fax:858-822-5380
Practice Address - Street 1:3855 HEALTH SCIENCES DR # 0658
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-0987
Practice Address - Country:US
Practice Address - Phone:858-822-6100
Practice Address - Fax:858-822-6186
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA84421207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology