Provider Demographics
NPI:1700915063
Name:PONGCHED, SUPACHAI S (MD)
Entity Type:Individual
Prefix:DR
First Name:SUPACHAI
Middle Name:S
Last Name:PONGCHED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SUPACHAI
Other - Middle Name:
Other - Last Name:SUWATANAPONGCHED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:17315 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-3553
Mailing Address - Country:US
Mailing Address - Phone:708-596-2445
Mailing Address - Fax:630-455-9633
Practice Address - Street 1:11416 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4932
Practice Address - Country:US
Practice Address - Phone:773-660-8515
Practice Address - Fax:630-455-9633
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILAP5130543OtherD.E.A.
ILAP5130543OtherD.E.A.