Provider Demographics
NPI:1790854388
Name:KULKAMTHORN, SIRIPORN (MD)
Entity Type:Individual
Prefix:DR
First Name:SIRIPORN
Middle Name:
Last Name:KULKAMTHORN
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 1:6125 CLAYTON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3266
Mailing Address - Country:US
Mailing Address - Phone:314-768-3034
Mailing Address - Fax:314-768-5607
Practice Address - Street 1:6125 CLAYTON AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-3266
Practice Address - Country:US
Practice Address - Phone:314-768-3034
Practice Address - Fax:314-768-5607
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO35164225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner