Provider Demographics
NPI:1558363713
Name:CHOTIPRASIDHI, POONPUTT (MD)
Entity Type:Individual
Prefix:DR
First Name:POONPUTT
Middle Name:
Last Name:CHOTIPRASIDHI
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 1:525 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6138
Mailing Address - Country:US
Mailing Address - Phone:309-601-2800
Mailing Address - Fax:309-601-2801
Practice Address - Street 1:525 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6138
Practice Address - Country:US
Practice Address - Phone:309-601-2800
Practice Address - Fax:309-601-2801
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103123207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103123Medicaid
ILP00155422OtherRAILROAD MEDICARE
IAI14117Medicare PIN
ILP00155422OtherRAILROAD MEDICARE
IL036103123Medicaid