Provider Demographics
NPI:1275656647
Name:CHANBUSARAKUM, PUANGPETCH
Entity Type:Individual
Prefix:DR
First Name:PUANGPETCH
Middle Name:
Last Name:CHANBUSARAKUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-1309
Mailing Address - Country:US
Mailing Address - Phone:608-267-1445
Mailing Address - Fax:
Practice Address - Street 1:722 WILLIAMSON ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-3546
Practice Address - Country:US
Practice Address - Phone:608-267-1445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine