Provider Demographics
NPI:1376656116
Name:WONGSURAWAT, NIRANDON (MD)
Entity Type:Individual
Prefix:DR
First Name:NIRANDON
Middle Name:
Last Name:WONGSURAWAT
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 1:1015 BOWLES AVE
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-1530
Mailing Address - Country:US
Mailing Address - Phone:636-566-8155
Mailing Address - Fax:314-966-0323
Practice Address - Street 1:1015 BOWLES AVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-1530
Practice Address - Country:US
Practice Address - Phone:636-566-8155
Practice Address - Fax:314-966-0323
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD34919207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205205701Medicaid
MOH25211Medicare UPIN
MO205205701Medicaid