Provider Demographics
NPI:1396758371
Name:SUPHAVEJKORNKIJ, CHANARONG (MD)
Entity type:Individual
Prefix:
First Name:CHANARONG
Middle Name:
Last Name:SUPHAVEJKORNKIJ
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 1:5 WOOD VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-4629
Mailing Address - Country:US
Mailing Address - Phone:443-881-4777
Mailing Address - Fax:410-881-4739
Practice Address - Street 1:5 WOODVALLEY CT
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-4629
Practice Address - Country:US
Practice Address - Phone:443-881-4777
Practice Address - Fax:443-881-4739
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0018970174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD790611100Medicaid
MDD84654Medicare UPIN
MD8389Medicare PIN