Provider Demographics
NPI:1093387672
Name:DHARMASAPUTRA, TARATHYA BUNGA (MD)
Entity type:Individual
Prefix:
First Name:TARATHYA
Middle Name:BUNGA
Last Name:DHARMASAPUTRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17350 HUMPHREYS PKWY UNIT 5303
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91387-3726
Mailing Address - Country:US
Mailing Address - Phone:312-478-7054
Mailing Address - Fax:718-963-7957
Practice Address - Street 1:15237 ELEVENTH ST STE A
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3736
Practice Address - Country:US
Practice Address - Phone:760-662-7420
Practice Address - Fax:760-513-9000
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA195428208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program