Provider Demographics
NPI:1316292931
Name:RATTANAVICH, RUNGWASEE
Entity type:Individual
Prefix:DR
First Name:RUNGWASEE
Middle Name:
Last Name:RATTANAVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:RUNGWASEE
Other - Middle Name:
Other - Last Name:RATTANAVICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:25865 BARTON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3896
Mailing Address - Country:US
Mailing Address - Phone:800-548-3790
Mailing Address - Fax:
Practice Address - Street 1:25865 BARTON RD STE 101
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3896
Practice Address - Country:US
Practice Address - Phone:909-558-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA157364207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine