Provider Demographics
NPI:1275630196
Name:ANGSUPANICH, KRAIVIT (MD)
Entity Type:Individual
Prefix:DR
First Name:KRAIVIT
Middle Name:
Last Name:ANGSUPANICH
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 1:801 11TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-4100
Mailing Address - Country:US
Mailing Address - Phone:707-262-5568
Mailing Address - Fax:707-263-6888
Practice Address - Street 1:801 11TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-4100
Practice Address - Country:US
Practice Address - Phone:707-262-5568
Practice Address - Fax:707-263-6888
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34208208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020049565OtherRAILROAD MEDICARE
CA00A3420800Medicare ID - Type Unspecified