Provider Demographics
NPI:1154326072
Name:RATTANANONT, PRASOP (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASOP
Middle Name:
Last Name:RATTANANONT
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 1:301 NW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:IL
Mailing Address - Zip Code:61231-1404
Mailing Address - Country:US
Mailing Address - Phone:309-582-5388
Mailing Address - Fax:309-582-5389
Practice Address - Street 1:301 NW 2ND ST
Practice Address - Street 2:
Practice Address - City:ALEDO
Practice Address - State:IL
Practice Address - Zip Code:61231-1404
Practice Address - Country:US
Practice Address - Phone:309-582-5388
Practice Address - Fax:309-582-5389
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
C43547Medicare UPIN
IL209626Medicare ID - Type Unspecified