Provider Demographics
NPI:1093885915
Name:POLYUDHAPOOM, APAI
Entity Type:Individual
Prefix:
First Name:APAI
Middle Name:
Last Name:POLYUDHAPOOM
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 1:1743 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-3031
Mailing Address - Country:US
Mailing Address - Phone:559-233-1188
Mailing Address - Fax:559-233-1189
Practice Address - Street 1:3233 N CHESTNUT AVE
Practice Address - Street 2:STE 102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6441
Practice Address - Country:US
Practice Address - Phone:559-233-1188
Practice Address - Fax:559-233-1189
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48979208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF27061Medicare UPIN