Provider Demographics
NPI:1255678983
Name:CHANGSIRIVATHANATHAMRONG, DECHABOON (MD)
Entity Type:Individual
Prefix:
First Name:DECHABOON
Middle Name:
Last Name:CHANGSIRIVATHANATHAMRONG
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 1:215 E 95TH ST
Mailing Address - Street 2:APT. 22B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-4077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 E 95TH ST
Practice Address - Street 2:APT. 22B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-4077
Practice Address - Country:US
Practice Address - Phone:212-427-1540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP82725390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program