1831109131 NPI number — DR. KANOKRAT SUKSOMPOTH M.D.

Table of content: DR. KANOKRAT SUKSOMPOTH M.D. (NPI 1831109131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831109131 NPI number — DR. KANOKRAT SUKSOMPOTH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUKSOMPOTH
Provider First Name:
KANOKRAT
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831109131
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 N INDIAN HILL BLVD
Provider Second Line Business Mailing Address:
PMB 801
Provider Business Mailing Address City Name:
CLAREMONT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91711-4611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-275-7470
Provider Business Mailing Address Fax Number:
909-971-4532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 E BONITA AVE BLDG 1B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POMONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91767-1923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-275-7470
Provider Business Practice Location Address Fax Number:
909-971-4532
Provider Enumeration Date:
08/09/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  35749 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: A96983 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 117346 . This is a "HEALTH CHOICE OF AZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 117346 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2Z7810 . This is a "HEALTH NET OF AZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 7789806 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".