Provider Demographics
NPI:1285675058
Name:JANTRA, PUANGPETH - (MD)
Entity Type:Individual
Prefix:DR
First Name:PUANGPETH
Middle Name:-
Last Name:JANTRA
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 1:4202 YORKSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2917
Mailing Address - Country:US
Mailing Address - Phone:847-480-9069
Mailing Address - Fax:312-569-8050
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-6380
Practice Address - Fax:312-569-8050
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation