Provider Demographics
NPI:1366062408
Name:SOEWONO, KATARINA ROSARI (MD)
Entity type:Individual
Prefix:
First Name:KATARINA
Middle Name:ROSARI
Last Name:SOEWONO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1111 E SPRUCE AVE STE 431
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3330
Mailing Address - Country:US
Mailing Address - Phone:559-450-7449
Mailing Address - Fax:559-450-7470
Practice Address - Street 1:4770 W HERNDON AVE STE 110
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-8401
Practice Address - Country:US
Practice Address - Phone:559-450-0463
Practice Address - Fax:559-450-0464
Is Sole Proprietor?:No
Enumeration Date:2020-04-18
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA183157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine