Provider Demographics
NPI:1205245024
Name:KLINOUBOL, POOVASIT (DPM)
Entity type:Individual
Prefix:
First Name:POOVASIT
Middle Name:
Last Name:KLINOUBOL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E SIDNEY AVE APT 7E
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-1419
Mailing Address - Country:US
Mailing Address - Phone:646-338-9832
Mailing Address - Fax:
Practice Address - Street 1:12 NORTH SEVENTH AVENUE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550
Practice Address - Country:US
Practice Address - Phone:646-338-9832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2018-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006854213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery