Provider Demographics
NPI:1790746840
Name:SUKSANONG, MINGQUAN TONGBHAKDEE (MD)
Entity Type:Individual
Prefix:
First Name:MINGQUAN
Middle Name:TONGBHAKDEE
Last Name:SUKSANONG
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:PO BOX 1945
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34682-1945
Mailing Address - Country:US
Mailing Address - Phone:727-771-1300
Mailing Address - Fax:727-781-2300
Practice Address - Street 1:1752 MLK JR ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-4206
Practice Address - Country:US
Practice Address - Phone:727-823-7224
Practice Address - Fax:727-489-9486
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0031666207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL52999OtherBCBS
FLP00883306OtherRAILROAD MEDICARE
FL160184600OtherWORK COMP
FL059830500Medicaid
FL059830500Medicaid
FL52999ZMedicare PIN