Provider Demographics
NPI:1407060031
Name:PHITAYAKORN, ROY (MD, MHPE)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:
Last Name:PHITAYAKORN
Suffix:
Gender:M
Credentials:MD, MHPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PARKMAN ST
Mailing Address - Street 2:WACC, SUITE 460
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-3117
Mailing Address - Country:US
Mailing Address - Phone:617-643-0544
Mailing Address - Fax:617-724-2574
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:WACC, SUITE 460
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-643-0544
Practice Address - Fax:617-724-2574
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA239064208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery