Provider Demographics
NPI:1912012022
Name:ISARIYAWONGSE, PRAKORB (MD)
Entity Type:Individual
Prefix:MR
First Name:PRAKORB
Middle Name:
Last Name:ISARIYAWONGSE
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 1:129 SIMPSON ROAD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BROWNSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15417
Mailing Address - Country:US
Mailing Address - Phone:724-785-9696
Mailing Address - Fax:724-785-7225
Practice Address - Street 1:129 SIMPSON ROAD
Practice Address - Street 2:SUITE 108
Practice Address - City:BROWNSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15417
Practice Address - Country:US
Practice Address - Phone:724-785-9696
Practice Address - Fax:724-785-7225
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033993L208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA202932OtherUPMC
60542OtherUNISON
PA7938474011OtherCIGNA
020031897OtherPALMETTO MEDICARE
0708585OtherUNITED MINE WORKERS
PA129649OtherHIGHMARK
PA0005869240004Medicaid
251310157OtherUNITED HEALTH CARE
PA18700OtherHEALTH AMERICA
PA129649OtherHIGHMARK
129649Medicare ID - Type Unspecified