Provider Demographics
NPI:1225242662
Name:SOONTARAPORNCHAI, KULTIDA (MD)
Entity Type:Individual
Prefix:DR
First Name:KULTIDA
Middle Name:
Last Name:SOONTARAPORNCHAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11714 LONGWORTH RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1322
Mailing Address - Country:US
Mailing Address - Phone:714-924-5698
Mailing Address - Fax:
Practice Address - Street 1:10001 S EASTERN AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3907
Practice Address - Country:US
Practice Address - Phone:702-566-2400
Practice Address - Fax:702-433-2477
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1558322080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program