Provider Demographics
NPI:1205003068
Name:WONGKITTIROCH, KHONGRUK (DO)
Entity Type:Individual
Prefix:
First Name:KHONGRUK
Middle Name:
Last Name:WONGKITTIROCH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2838 E OAKLAND PARK BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1814
Mailing Address - Country:US
Mailing Address - Phone:954-564-0040
Mailing Address - Fax:
Practice Address - Street 1:2838 E OAKLAND PARK BLVD
Practice Address - Street 2:STE 201
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1814
Practice Address - Country:US
Practice Address - Phone:954-564-0040
Practice Address - Fax:954-564-0048
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11792207N00000X, 207NI0002X, 207ND0900X, 207ND0101X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28528OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL261637814OtherMULTI PLAN
FL317129OtherAVMED
FL261637814OtherUNITED HEALTHCARE
FL6375863OtherCIGNA
FL28528OtherBLUE CROSS BLUE SHIELD OF FLORIDA