Provider Demographics
NPI:1124075502
Name:NUCHNIYOM, BURIN (MD)
Entity type:Individual
Prefix:
First Name:BURIN
Middle Name:
Last Name:NUCHNIYOM
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 1:604 MUIRWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-3624
Mailing Address - Country:US
Mailing Address - Phone:601-668-5850
Mailing Address - Fax:
Practice Address - Street 1:604 MUIRWOOD CIR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-3624
Practice Address - Country:US
Practice Address - Phone:601-668-5850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52887207R00000X
MS15550207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119043Medicaid
G62464Medicare UPIN