Provider Demographics
NPI:1922254184
Name:LISAWAT, PANUPONG (MD)
Entity Type:Individual
Prefix:
First Name:PANUPONG
Middle Name:
Last Name:LISAWAT
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 1:111 OSBORNE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6000
Mailing Address - Country:US
Mailing Address - Phone:203-739-7104
Mailing Address - Fax:
Practice Address - Street 1:111 OSBORNE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6000
Practice Address - Country:US
Practice Address - Phone:203-739-7104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT051569208M00000X, 207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine