Provider Demographics
NPI:1629280664
Name:KIRATISEAVEE, SIWAT (MD)
Entity Type:Individual
Prefix:
First Name:SIWAT
Middle Name:
Last Name:KIRATISEAVEE
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 1:208 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1160
Mailing Address - Country:US
Mailing Address - Phone:304-343-4300
Mailing Address - Fax:304-343-5473
Practice Address - Street 1:208 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-1160
Practice Address - Country:US
Practice Address - Phone:304-343-4300
Practice Address - Fax:304-343-5473
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP48044207K00000X
WV22761207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009489Medicaid
WV3810009489Medicaid