Provider Demographics
NPI:1508126590
Name:CHATSUDTHIPONG, ATIP (MD)
Entity Type:Individual
Prefix:
First Name:ATIP
Middle Name:
Last Name:CHATSUDTHIPONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2160 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1410
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:207 QUAKER LN FL 1
Practice Address - Street 2:
Practice Address - City:WEST WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02893-2179
Practice Address - Country:US
Practice Address - Phone:401-828-7110
Practice Address - Fax:401-827-6364
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD16055208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology