Provider Demographics
NPI:1629210950
Name:WITTAYA PAYACKAPAN MD. PC
Entity type:Organization
Organization Name:WITTAYA PAYACKAPAN MD. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WITTAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYACKAPAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-842-6626
Mailing Address - Street 1:365 BROADWAY
Mailing Address - Street 2:SUITE #5
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:631-842-6626
Mailing Address - Fax:631-842-6609
Practice Address - Street 1:365 BROADWAY
Practice Address - Street 2:SUITE #5
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11743
Practice Address - Country:US
Practice Address - Phone:631-842-6626
Practice Address - Fax:631-842-6609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00349615Medicaid
NY00349615Medicaid