Provider Demographics
NPI:1497847206
Name:CHARNVITAYAPONG, KASEM (MD)
Entity Type:Individual
Prefix:
First Name:KASEM
Middle Name:
Last Name:CHARNVITAYAPONG
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 1:2221 SE OCEAN BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34996-3341
Mailing Address - Country:US
Mailing Address - Phone:772-283-4428
Mailing Address - Fax:
Practice Address - Street 1:2221 SE OCEAN BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3341
Practice Address - Country:US
Practice Address - Phone:772-283-4428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073266207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253176300Medicaid
FL1497847206Medicare PIN
41560ZMedicare ID - Type Unspecified
FL253176300Medicaid