Provider Demographics
NPI:1649320987
Name:SOMBUTMAI, CHUT (DO)
Entity type:Individual
Prefix:
First Name:CHUT
Middle Name:
Last Name:SOMBUTMAI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 METRO PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1206
Mailing Address - Country:US
Mailing Address - Phone:239-984-6839
Mailing Address - Fax:
Practice Address - Street 1:11215 METRO PKWY STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1206
Practice Address - Country:US
Practice Address - Phone:239-208-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0196172084N0400X
NH174442084N0400X
NC2010-017652084N0400X
FLOS107702084N0400X, 2084N0400X
MI51010237332084N0400X
TXTM007252084N0400X
ORDO1861412084N0400X
ND149202084N0400X
OH34.0130702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3115195Medicaid
SCNC2334Medicaid
NC232009OtherMEDICARE PTAN, GROUP
NCNC2804AOtherMEDICARE PTAN, INDIVIDUAL
NC5918230Medicaid
NC232009OtherMEDICARE PTAN, GROUP
NCNC2804BMedicare PIN