Provider Demographics
NPI:1073834339
Name:PATTHANACHAROENPHON, CAMERON (MD)
Entity Type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:
Last Name:PATTHANACHAROENPHON
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 1:14650 E OLD US HIGHWAY 12 STE 104
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118-1801
Mailing Address - Country:US
Mailing Address - Phone:734-593-5700
Mailing Address - Fax:
Practice Address - Street 1:14650 E OLD US HIGHWAY 12 STE 104
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1801
Practice Address - Country:US
Practice Address - Phone:734-593-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096531207XX0004X
WAMD60537463207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1073834339Medicaid
MI1073834339Medicaid