1871089367 NPI number — MISS KHEMAPORN LERTDETKAJORN MD

Table of content: MISS KHEMAPORN LERTDETKAJORN MD (NPI 1871089367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871089367 NPI number — MISS KHEMAPORN LERTDETKAJORN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LERTDETKAJORN
Provider First Name:
KHEMAPORN
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1871089367
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 UPPER RIVERDALE RD SW STE 111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERDALE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30274-2642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-909-2045
Provider Business Mailing Address Fax Number:
770-909-2056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 UPPER RIVERDALE RD SW STE 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERDALE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30274-2642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-909-2045
Provider Business Practice Location Address Fax Number:
770-909-2056
Provider Enumeration Date:
07/08/2018

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: 207RE0101X , with the licence number:  100193 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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