1417695412 NPI number — MR. GRITCHALACH PHOPHUTTHAPRASIT AP, DOM

Table of content: MR. GRITCHALACH PHOPHUTTHAPRASIT AP, DOM (NPI 1417695412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417695412 NPI number — MR. GRITCHALACH PHOPHUTTHAPRASIT AP, DOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHOPHUTTHAPRASIT
Provider First Name:
GRITCHALACH
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
AP, DOM
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:
1417695412
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2501 S VOLUSIA AVE STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32763-9134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-774-3333
Provider Business Mailing Address Fax Number:
386-410-1603

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3739 LAKE CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT DORA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32757-2363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-729-2290
Provider Business Practice Location Address Fax Number:
386-774-6333
Provider Enumeration Date:
05/20/2022

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: 171100000X , with the licence number:  AP4357 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117771900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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