Provider Demographics
NPI:1396996294
Name:TANGCHITNOB, EDWARD PAKORN (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:PAKORN
Last Name:TANGCHITNOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 S SUNSET AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3937
Mailing Address - Country:US
Mailing Address - Phone:626-338-5377
Mailing Address - Fax:
Practice Address - Street 1:1135 S SUNSET AVE STE 102
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3937
Practice Address - Country:US
Practice Address - Phone:626-338-5377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA110608207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1396996294OtherPTAN
CACB208996OtherPTAN
CA1063842649Medicaid