Provider Demographics
NPI:1598849192
Name:UDOMPHONKUL, NIKOM (MD)
Entity Type:Individual
Prefix:DR
First Name:NIKOM
Middle Name:
Last Name:UDOMPHONKUL
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:PO BOX 947
Mailing Address - Street 2:
Mailing Address - City:GRIDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95948
Mailing Address - Country:US
Mailing Address - Phone:530-846-3604
Mailing Address - Fax:530-846-2108
Practice Address - Street 1:284 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GRIDLEY
Practice Address - State:CA
Practice Address - Zip Code:95948-2216
Practice Address - Country:US
Practice Address - Phone:530-846-9035
Practice Address - Fax:530-846-9075
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34194207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A34194Medicaid
CA00A34194Medicaid
CAZZZ86416ZMedicare ID - Type Unspecified