Provider Demographics
NPI:1366690844
Name:PUPAIBOOL, JAKRAPUN (MD)
Entity Type:Individual
Prefix:
First Name:JAKRAPUN
Middle Name:
Last Name:PUPAIBOOL
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:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4316
Mailing Address - Fax:
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:SUITE 3050
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-3905
Practice Address - Fax:417-820-3528
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012034336207RI0200X
MN53446207RI0200X
MN104898207RI0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MOPENDINGMedicaid
MOPENDINGMedicaid
MN440000295Medicare PIN