Provider Demographics
NPI:1205090297
Name:PHISITKUL, PHINIT (MD)
Entity type:Individual
Prefix:
First Name:PHINIT
Middle Name:
Last Name:PHISITKUL
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 1:2730 PIERCE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-3796
Mailing Address - Country:US
Mailing Address - Phone:712-224-8677
Mailing Address - Fax:712-277-1662
Practice Address - Street 1:2730 PIERCE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-3796
Practice Address - Country:US
Practice Address - Phone:712-224-8677
Practice Address - Fax:712-277-1662
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36706207X00000X, 207XX0004X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI0923108Medicare PIN
IAP00701720Medicare PIN