Provider Demographics
NPI:1114083888
Name:SUNTHARASANTIC, SIRISAK (MD)
Entity Type:Individual
Prefix:DR
First Name:SIRISAK
Middle Name:
Last Name:SUNTHARASANTIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SIRISAK
Other - Middle Name:
Other - Last Name:SUN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4 MEMORIAL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6751
Mailing Address - Country:US
Mailing Address - Phone:618-463-0649
Mailing Address - Fax:618-463-3390
Practice Address - Street 1:4 MEMORIAL DR STE 210
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6751
Practice Address - Country:US
Practice Address - Phone:618-463-0649
Practice Address - Fax:618-463-3390
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048367208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048367Medicaid
ILL65497Medicare ID - Type Unspecified
IL036048367Medicaid