Provider Demographics
NPI:1487005062
Name:PHUPITAKPHOL, TANIT (MD)
Entity Type:Individual
Prefix:
First Name:TANIT
Middle Name:
Last Name:PHUPITAKPHOL
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 1:130 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2803
Mailing Address - Country:US
Mailing Address - Phone:508-941-7268
Mailing Address - Fax:508-894-0412
Practice Address - Street 1:130 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2803
Practice Address - Country:US
Practice Address - Phone:508-941-7268
Practice Address - Fax:508-894-0412
Is Sole Proprietor?:No
Enumeration Date:2016-06-25
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA286943207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease