Provider Demographics
NPI:1225255243
Name:KULWATDANAPORN, SOMCHAI (MD)
Entity Type:Individual
Prefix:DR
First Name:SOMCHAI
Middle Name:
Last Name:KULWATDANAPORN
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 1:645 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07514-1926
Mailing Address - Country:US
Mailing Address - Phone:973-742-2077
Mailing Address - Fax:973-653-3585
Practice Address - Street 1:645 BROADWAY
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-1926
Practice Address - Country:US
Practice Address - Phone:201-962-8536
Practice Address - Fax:201-962-8536
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA035607207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ449091OtherMEDICARE
NJC54934Medicare UPIN