Provider Demographics
NPI:1831109131
Name:SUKSOMPOTH, KANOKRAT (MD)
Entity Type:Individual
Prefix:DR
First Name:KANOKRAT
Middle Name:
Last Name:SUKSOMPOTH
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 1:310 N INDIAN HILL BLVD
Mailing Address - Street 2:PMB 801
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4611
Mailing Address - Country:US
Mailing Address - Phone:909-275-7470
Mailing Address - Fax:909-971-4532
Practice Address - Street 1:255 E BONITA AVE BLDG 1B
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1923
Practice Address - Country:US
Practice Address - Phone:909-275-7470
Practice Address - Fax:909-971-4532
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35749207R00000X
CAA96983207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ117346OtherHEALTH CHOICE OF AZ
AZ117346Medicaid
AZ2Z7810OtherHEALTH NET OF AZ
AZ7789806OtherAETNA
AZ117346OtherHEALTH CHOICE OF AZ