Provider Demographics
NPI:1235572991
Name:CHUPATANAKUL, LALIDA (MD)
Entity Type:Individual
Prefix:
First Name:LALIDA
Middle Name:
Last Name:CHUPATANAKUL
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 1:3285 S VAL VISTA DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7000
Mailing Address - Country:US
Mailing Address - Phone:480-397-2800
Mailing Address - Fax:
Practice Address - Street 1:3285 S VAL VISTA DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297
Practice Address - Country:US
Practice Address - Phone:480-397-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67552-20207Q00000X, 207QG0300X
IL036139532207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILRES000Medicare UPIN