Provider Demographics
NPI:1164539995
Name:KANKIRAWATANA, PONGKIAT (MD)
Entity Type:Individual
Prefix:
First Name:PONGKIAT
Middle Name:
Last Name:KANKIRAWATANA
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 1:1600 7TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1711
Mailing Address - Country:US
Mailing Address - Phone:205-996-7850
Mailing Address - Fax:
Practice Address - Street 1:1600 7TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1711
Practice Address - Country:US
Practice Address - Phone:205-996-7850
Practice Address - Fax:205-996-7867
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL241082084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009966020Medicaid
MS05626087Medicaid
AL009966030Medicaid
051504373Medicare ID - Type Unspecified
H57691Medicare UPIN
AL009966030Medicaid