Provider Demographics
NPI:1205099082
Name:KIATSIMKUL, PORNTIP (MD)
Entity type:Individual
Prefix:
First Name:PORNTIP
Middle Name:
Last Name:KIATSIMKUL
Suffix:
Gender:
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:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3640 NW SAMARITAN DR STE 210
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3787
Practice Address - Country:US
Practice Address - Phone:541-768-5810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME132818207RI0200X
ORMD222762207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty