Provider Demographics
NPI:1275563462
Name:WATANAKUNAKORN, PAUL W (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:WATANAKUNAKORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:20 OHLTOWN RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-2331
Mailing Address - Country:US
Mailing Address - Phone:330-797-9705
Mailing Address - Fax:330-270-5997
Practice Address - Street 1:20 OHLTOWN RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2331
Practice Address - Country:US
Practice Address - Phone:330-797-9705
Practice Address - Fax:330-270-5997
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076990207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHZ76990OtherSUMMACARE
OH000000280876OtherANTHEM BC/BS
OHP00013192OtherRAILROAD MEDICARE
OH341341025030OtherCARESOURCE
OHQ034637OtherHOMETOWN
OH001467940OtherHIGHMARK BC/BS PA
OH225394OtherHEALTH ASSURANCE
OH407998OtherUNITED HEALTHCARE
OH2300585Medicaid
OHQ034637OtherHOMETOWN
OH000000280876OtherANTHEM BC/BS
OHP00013192OtherRAILROAD MEDICARE
OHWA4064234Medicare PIN
OHP00013192OtherRAILROAD MEDICARE