Provider Demographics
NPI:1568759512
Name:PISOH, WATCOUN-NCHINDA EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:WATCOUN-NCHINDA
Middle Name:EDWARD
Last Name:PISOH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PISOH
Other - Middle Name:EDWARD
Other - Last Name:WATCOUN-NCHINDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:157 CLINIC AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4454
Mailing Address - Country:US
Mailing Address - Phone:770-214-2800
Mailing Address - Fax:770-214-2803
Practice Address - Street 1:157 CLINIC AVE STE 201
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4454
Practice Address - Country:US
Practice Address - Phone:770-214-2800
Practice Address - Fax:770-214-2803
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA92532207RG0100X
IL036.135066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003273458AMedicaid
IL036135066Medicaid