Provider Demographics
NPI:1033377528
Name:KHONGKHATITHUM, CHAIYOS (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAIYOS
Middle Name:
Last Name:KHONGKHATITHUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12000 FAIRHILL RD
Mailing Address - Street 2:APT. G1
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-1035
Mailing Address - Country:US
Mailing Address - Phone:216-466-3510
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:UT SOUTHWESTERN MEDICAL CENTER, DIV. OF PEDIATRIC NEURO
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:214-456-8242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57012391390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program