Provider Demographics
NPI:1639124530
Name:PHORNPHUTKUL, CHANIKA (MD)
Entity Type:Individual
Prefix:
First Name:CHANIKA
Middle Name:
Last Name:PHORNPHUTKUL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:HASBRO 122
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-8361
Mailing Address - Fax:401-444-3288
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-8361
Practice Address - Fax:401-444-3288
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI101212080P0205X
RIMD10121207SG0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical Genetics
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RICP46587Medicaid
RIH71415Medicare UPIN
RI007010049Medicare PIN