Provider Demographics
NPI:1295925030
Name:SRISAWAT, ANUNPORN (MD)
Entity type:Individual
Prefix:
First Name:ANUNPORN
Middle Name:
Last Name:SRISAWAT
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:PO BOX 290035
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-0035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4554 S CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-5403
Practice Address - Country:US
Practice Address - Phone:386-304-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 95967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine