Provider Demographics
NPI:1225095466
Name:RATARASARN, PICHAYA SARASOMBATH (MD)
Entity Type:Individual
Prefix:
First Name:PICHAYA
Middle Name:SARASOMBATH
Last Name:RATARASARN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PICHAYA
Other - Middle Name:A
Other - Last Name:SARASOMBATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3700 PARMENTER ST APT 205
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-1537
Mailing Address - Country:US
Mailing Address - Phone:414-243-2999
Mailing Address - Fax:
Practice Address - Street 1:3051 CAHILL MAIN
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-7109
Practice Address - Country:US
Practice Address - Phone:608-661-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48712-020207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00725804OtherRR MEDICARE
WI46236-0383Medicare PIN
WI01994-0382Medicare PIN