Provider Demographics
NPI:1053304428
Name:POW-ANPONGKUL, SOMNUK (MD)
Entity Type:Individual
Prefix:
First Name:SOMNUK
Middle Name:
Last Name:POW-ANPONGKUL
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 1:1101 OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 OCILLA RD
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2207
Practice Address - Country:US
Practice Address - Phone:912-384-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0297562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00344748BMedicaid
GA029756OtherSTATE LICENSE
GA029756OtherSTATE LICENSE
GA00344748BMedicaid