Provider Demographics
NPI:1245349315
Name:POOSUTHASEE, BANPOTE (MD)
Entity type:Individual
Prefix:
First Name:BANPOTE
Middle Name:
Last Name:POOSUTHASEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BANPOTE
Other - Middle Name:
Other - Last Name:POOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:SEBREE
Mailing Address - State:KY
Mailing Address - Zip Code:42455-0426
Mailing Address - Country:US
Mailing Address - Phone:270-835-7541
Mailing Address - Fax:
Practice Address - Street 1:47 W.WEBSTER STREET
Practice Address - Street 2:
Practice Address - City:SEBREE
Practice Address - State:KY
Practice Address - Zip Code:42455-0426
Practice Address - Country:US
Practice Address - Phone:270-835-7541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24993207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000049005OtherANTHEM BCBS
198961OtherBLACK LUNG
KY64249931Medicaid
KY1456902Medicare ID - Type Unspecified
KY000000049005OtherANTHEM BCBS