Provider Demographics
NPI:1396710893
Name:SRIVATANA, UKORN (MD)
Entity type:Individual
Prefix:DR
First Name:UKORN
Middle Name:
Last Name:SRIVATANA
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237737-1207RG0100X
PAMD068303L207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018809680001Medicaid
NYCC8362OtherRR MEDICARE GROUP
PACC9269OtherRR MEDICARE GROUP
NY02238397Medicaid
PAGU039897OtherPA MEDICARE GROUP
PA10016154OtherRR MEDICARE GROUP
NYP00318222OtherRAILROAD PIN
PACC9269OtherRR MEDICARE GROUP
PA0018809680001Medicaid
PA055043N9LMedicare PIN