Provider Demographics
NPI:1417949686
Name:PAKSAICHOL, KRUAWAN - (MD)
Entity Type:Individual
Prefix:DR
First Name:KRUAWAN
Middle Name:-
Last Name:PAKSAICHOL
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 1:25555 149TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2812
Mailing Address - Country:US
Mailing Address - Phone:718-712-2849
Mailing Address - Fax:718-922-3765
Practice Address - Street 1:123 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-2428
Practice Address - Country:US
Practice Address - Phone:718-922-3765
Practice Address - Fax:718-922-3765
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135912207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00427610Medicaid
NY54D612Medicare ID - Type Unspecified
NY00427610Medicaid