Provider Demographics
NPI:1871661793
Name:LERTWONGKANAKOOL, SUVEPA (DPM)
Entity type:Individual
Prefix:
First Name:SUVEPA
Middle Name:
Last Name:LERTWONGKANAKOOL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 GRANVILLE AVENUE
Mailing Address - Street 2:#1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1685
Mailing Address - Country:US
Mailing Address - Phone:310-231-4391
Mailing Address - Fax:310-231-4390
Practice Address - Street 1:1234 GRANVILLE AVENUE
Practice Address - Street 2:#1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1685
Practice Address - Country:US
Practice Address - Phone:310-231-4391
Practice Address - Fax:310-231-4390
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3715213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA480016471OtherRAILROAD MEDICARE
CA000E37150Medicaid
CAE3715Medicare PIN
CA480016471OtherRAILROAD MEDICARE