Provider Demographics
NPI:1073624375
Name:COUROPMITREE, CHAIYAPON (MD)
Entity Type:Individual
Prefix:MR
First Name:CHAIYAPON
Middle Name:
Last Name:COUROPMITREE
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 1:3416 HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2604
Mailing Address - Country:US
Mailing Address - Phone:708-442-6161
Mailing Address - Fax:708-442-7188
Practice Address - Street 1:3416 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2604
Practice Address - Country:US
Practice Address - Phone:708-442-6161
Practice Address - Fax:708-442-7188
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-045186207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-045186OtherSTATE LICENSE NUMBER
IL036-045186OtherSTATE LICENSE NUMBER