Provider Demographics
NPI:1194962076
Name:TRIKADIBUSANA, SANDJAYA (MSOM/DAOM CANDIDATE)
Entity type:Individual
Prefix:DR
First Name:SANDJAYA
Middle Name:
Last Name:TRIKADIBUSANA
Suffix:
Gender:M
Credentials:MSOM/DAOM CANDIDATE
Other - Prefix:DR
Other - First Name:SANDJAYA
Other - Middle Name:
Other - Last Name:TRI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSOM/DAOM CANDIDATE
Mailing Address - Street 1:1126 N BROOKHURST ST,
Mailing Address - Street 2:SOUTH BAYLO UNIVERSITY, 3RD FLOOR
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801
Mailing Address - Country:US
Mailing Address - Phone:562-866-5830
Mailing Address - Fax:
Practice Address - Street 1:1126 N BROOKHURST ST,
Practice Address - Street 2:SOUTH BAYLO UNIVERSITY, 3RD FLOOR
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801
Practice Address - Country:US
Practice Address - Phone:562-866-5830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 8055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist