Provider Demographics
NPI:1578634242
Name:PATANAPHAN, PEYAPONG (MD)
Entity Type:Individual
Prefix:
First Name:PEYAPONG
Middle Name:
Last Name:PATANAPHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PAT
Other - Middle Name:
Other - Last Name:TANA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1 ROLAND CT
Mailing Address - Street 2:
Mailing Address - City:RUXTON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-3550
Mailing Address - Country:US
Mailing Address - Phone:410-337-8805
Mailing Address - Fax:
Practice Address - Street 1:200 E 33RD ST
Practice Address - Street 2:SUITE 631
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-3322
Practice Address - Country:US
Practice Address - Phone:410-532-4848
Practice Address - Fax:410-554-4455
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD21797174400000X
MDD0021797207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD979801300Medicaid
MD979801300Medicaid
MD6653Medicare PIN