Provider Demographics
NPI:1083879084
Name:CHAIWONGKARJOHN, SUTTIRAK
Entity Type:Individual
Prefix:
First Name:SUTTIRAK
Middle Name:
Last Name:CHAIWONGKARJOHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45104 10TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2310
Mailing Address - Country:US
Mailing Address - Phone:661-942-2391
Mailing Address - Fax:
Practice Address - Street 1:45104 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2310
Practice Address - Country:US
Practice Address - Phone:661-942-2391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-20
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115809208D00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice