Provider Demographics
NPI:1174726954
Name:CHAISANGUANTHUM, ROSLYN MIANGLEE (MD)
Entity type:Individual
Prefix:DR
First Name:ROSLYN
Middle Name:MIANGLEE
Last Name:CHAISANGUANTHUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11356 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5554
Mailing Address - Country:US
Mailing Address - Phone:626-378-2209
Mailing Address - Fax:
Practice Address - Street 1:14445 OLIVE VIEW DR
Practice Address - Street 2:ROOM 2B-182
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1437
Practice Address - Country:US
Practice Address - Phone:818-364-3205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84781174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist