Provider Demographics
NPI:1255759171
Name:CHITTCHANG, SASITHORN (MD)
Entity type:Individual
Prefix:
First Name:SASITHORN
Middle Name:
Last Name:CHITTCHANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2338 DANIELS RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT
Mailing Address - State:MD
Mailing Address - Zip Code:21043
Mailing Address - Country:US
Mailing Address - Phone:410-461-9308
Mailing Address - Fax:
Practice Address - Street 1:2338 DANIELS RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT
Practice Address - State:MD
Practice Address - Zip Code:21043
Practice Address - Country:US
Practice Address - Phone:410-461-9308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-29
Last Update Date:2014-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0016267208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD00594Medicaid
MD2266Medicare UPIN