Provider Demographics
NPI:1659430403
Name:TANAPAT, PRASERT (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASERT
Middle Name:
Last Name:TANAPAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PRASERT
Other - Middle Name:
Other - Last Name:TANAPATCHAIYAPONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9 HORIZON RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11020-1143
Mailing Address - Country:US
Mailing Address - Phone:516-466-6317
Mailing Address - Fax:516-466-6317
Practice Address - Street 1:23 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-5103
Practice Address - Country:US
Practice Address - Phone:516-379-5299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYMD 113836207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY46A48Medicare ID - Type UnspecifiedBLUE CROSS & BLUE SHIELD
NYB14911Medicare UPIN