Provider Demographics
NPI:1699818658
Name:SRISURO, CHOTCHAI (MD)
Entity Type:Individual
Prefix:
First Name:CHOTCHAI
Middle Name:
Last Name:SRISURO
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 1:533 COUCH AVE
Mailing Address - Street 2:SUITE 287
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5561
Mailing Address - Country:US
Mailing Address - Phone:314-821-9144
Mailing Address - Fax:314-821-8019
Practice Address - Street 1:533 COUCH AVE
Practice Address - Street 2:SUITE 287
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-5561
Practice Address - Country:US
Practice Address - Phone:314-821-9144
Practice Address - Fax:314-821-8019
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33186207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA26378Medicare UPIN