Provider Demographics
NPI:1205852514
Name:ENKVETCHAKUL, DECHA (MD)
Entity Type:Individual
Prefix:DR
First Name:DECHA
Middle Name:
Last Name:ENKVETCHAKUL
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 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8126
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-7603
Mailing Address - Fax:314-361-4197
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:5TH FLOOR, SUITE C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-7603
Practice Address - Fax:314-361-4197
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103678207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205238603Medicaid
IL$$$$$$$$$Medicaid
H30286Medicare UPIN
341010183Medicare PIN
IL$$$$$$$$$Medicaid