Basic Information
| Provider Information | |||||||||
| NPI: | 1043337173 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUDIHARDJO | ||||||||
| FirstName: | IMAWATI | ||||||||
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| Credential: | M.D., PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3855 HEALTH SCIENCES DRIVE | ||||||||
| Address2: | ROOM 2016 | ||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920930698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588227916 | ||||||||
| FaxNumber: | 8588225380 | ||||||||
| Practice Location | |||||||||
| Address1: | 3855 HEALTH SCIENCES DR # 0658 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920930987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588226100 | ||||||||
| FaxNumber: | 8588226186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 10/12/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | A84421 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No ID Information.