Provider Demographics
NPI:1720073232
Name:KITTIMONGCOLPORN, SAOWARUT (MD)
Entity Type:Individual
Prefix:MS
First Name:SAOWARUT
Middle Name:
Last Name:KITTIMONGCOLPORN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 HARRISON AVE NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502
Mailing Address - Country:US
Mailing Address - Phone:360-786-6750
Mailing Address - Fax:360-786-1089
Practice Address - Street 1:1722 HARRISON AVE NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502
Practice Address - Country:US
Practice Address - Phone:360-786-6750
Practice Address - Fax:360-786-1089
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000371122084P0800X
ORMD240842084P0800X
CAA0662362084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H05109Medicare UPIN
WA8856001Medicare ID - Type Unspecified