Provider Demographics
NPI:1144234956
Name:PITTAYATHIKHUN, TEERA (MD)
Entity Type:Individual
Prefix:MR
First Name:TEERA
Middle Name:
Last Name:PITTAYATHIKHUN
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 1:211A SOUTH BURNS
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286
Mailing Address - Country:US
Mailing Address - Phone:618-443-3522
Mailing Address - Fax:618-443-5036
Practice Address - Street 1:211A SOUTH BURNS
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286
Practice Address - Country:US
Practice Address - Phone:618-443-3522
Practice Address - Fax:618-443-5036
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36047341208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
291800Medicare ID - Type Unspecified
D10739Medicare UPIN
291801Medicare ID - Type Unspecified