Provider Demographics
NPI:1841421989
Name:DANCHAIVIJITR, PONGWUT (MD)
Entity Type:Individual
Prefix:
First Name:PONGWUT
Middle Name:
Last Name:DANCHAIVIJITR
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 1:6565 N CHARLES ST
Mailing Address - Street 2:PPE SUITE 203
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6800
Mailing Address - Country:US
Mailing Address - Phone:443-849-2682
Mailing Address - Fax:443-849-8030
Practice Address - Street 1:6565 N CHARLES ST
Practice Address - Street 2:PPE SUITE 203
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6800
Practice Address - Country:US
Practice Address - Phone:443-849-2682
Practice Address - Fax:443-849-8030
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP24253207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine