Provider Demographics
NPI:1245315365
Name:LAOWATTANA, SOMCHAI (MD)
Entity type:Individual
Prefix:
First Name:SOMCHAI
Middle Name:
Last Name:LAOWATTANA
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 1:12632 S HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1428
Mailing Address - Country:US
Mailing Address - Phone:708-587-0000
Mailing Address - Fax:708-623-7628
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5200
Practice Address - Fax:414-259-0469
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361549602084N0400X
WI52265-202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1245315365Medicaid
68015-0109Medicare PIN