Provider Demographics
NPI:1588643449
Name:SIRIJINTAKARN, PAKORN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAKORN
Middle Name:
Last Name:SIRIJINTAKARN
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 1:2520 ELISHA AVENUE
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099
Mailing Address - Country:US
Mailing Address - Phone:847-872-6259
Mailing Address - Fax:847-872-5716
Practice Address - Street 1:2361 PAYSPHERE CIRCLE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60674
Practice Address - Country:US
Practice Address - Phone:847-746-4358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247100000X
IL036.0470992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC41745Medicare UPIN
L73613Medicare UPIN