Provider Demographics
NPI:1790749737
Name:KITIPHONGSPATTANA, KRIENGKRAI (MD)
Entity Type:Individual
Prefix:
First Name:KRIENGKRAI
Middle Name:
Last Name:KITIPHONGSPATTANA
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 1:20 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601
Mailing Address - Country:US
Mailing Address - Phone:304-831-1254
Mailing Address - Fax:304-831-1679
Practice Address - Street 1:20 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-0656
Practice Address - Country:US
Practice Address - Phone:304-831-1254
Practice Address - Fax:304-831-1679
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12458208600000X, 2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Not Answered208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0128282000Medicaid
WV0128282000Medicaid
WVF13406Medicare UPIN