Provider Demographics
NPI:1295861581
Name:LAOHABURANAKIT, PETEY (MD)
Entity Type:Individual
Prefix:
First Name:PETEY
Middle Name:
Last Name:LAOHABURANAKIT
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 1:2011 U ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-1771
Mailing Address - Country:US
Mailing Address - Phone:541-531-6227
Mailing Address - Fax:
Practice Address - Street 1:6600 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4671
Practice Address - Country:US
Practice Address - Phone:916-688-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25000207RP1001X
CAA72406207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275120Medicaid
OR275120Medicaid
OR0000WCJGJMedicare ID - Type UnspecifiedMEDICARE GROUP #