Provider Demographics
NPI:1821191107
Name:PUANGSUVAN, SOMPORN (MD)
Entity Type:Individual
Prefix:DR
First Name:SOMPORN
Middle Name:
Last Name:PUANGSUVAN
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:PO BOX1155
Mailing Address - Street 2:418 WARD AVENUE
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830
Mailing Address - Country:US
Mailing Address - Phone:573-333-0156
Mailing Address - Fax:573-333-0156
Practice Address - Street 1:106 W 12TH ST
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830-1890
Practice Address - Country:US
Practice Address - Phone:573-333-1124
Practice Address - Fax:573-333-1124
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7161208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200217818Medicaid
826021923OtherRAILROAD MEDICARE
A11866Medicare UPIN
826021923OtherRAILROAD MEDICARE