Provider Demographics
NPI:1255329371
Name:SONGCHAROEN, SUTHIN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUTHIN
Middle Name:
Last Name:SONGCHAROEN
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 1:2 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-9749
Mailing Address - Country:US
Mailing Address - Phone:601-856-7372
Mailing Address - Fax:601-420-5482
Practice Address - Street 1:2550 FLOWOOD DR
Practice Address - Street 2:#300
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9303
Practice Address - Country:US
Practice Address - Phone:601-420-0034
Practice Address - Fax:601-420-5482
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07163174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CK7048OtherMEDICARE RAILROAD GROUP
MS00119405Medicaid
C03036OtherMEDICARE PTAN
660002223OtherMEDICARE RAILROAD
MSC48232Medicare UPIN
MS660000015Medicare ID - Type Unspecified
MS00119405Medicaid