1174906002 NPI number — JIRAPAT TEERAKANOK MD

Table of content: JIRAPAT TEERAKANOK MD (NPI 1174906002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174906002 NPI number — JIRAPAT TEERAKANOK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEERAKANOK
Provider First Name:
JIRAPAT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1174906002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 LAKE AVENUE NORTH
Provider Second Line Business Mailing Address:
RHEUMATOLOGY
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-856-6246
Provider Business Mailing Address Fax Number:
508-856-4770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 BELMONT STREET
Provider Second Line Business Practice Location Address:
RHEUMATOLOGY
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-334-5224
Provider Business Practice Location Address Fax Number:
508-334-5654
Provider Enumeration Date:
07/09/2015

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: M2365 , registered in the state of GU ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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