Basic Information
| Provider Information | |||||||||
| NPI: | 1114313616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRIWONGTONG | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 S FETTERLY AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900221605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233621010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 834 CASTRO ST | ||||||||
| Address2: | 3 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941142858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159400264 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 145266 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.