Provider Demographics
NPI:1740252345
Name:SUTTHIWAN, PIRAON (MD)
Entity type:Individual
Prefix:DR
First Name:PIRAON
Middle Name:
Last Name:SUTTHIWAN
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 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:1836 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5429
Practice Address - Country:US
Practice Address - Phone:608-782-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8970207R00000X, 207RC0000X
WI53926207RC0000X
IA38974207RC0000X
MN53203207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144017101Medicaid
TX450686CI134021OtherSECTION 1011
NM202000019Medicaid
TX87915ZOtherHMO BLUE
TX174287602Medicaid
OK200056480AMedicaid
TX174287601Medicaid
TX8S5200OtherBC/BS
TX144017100OtherFIRSTCARE COMMERCIAL
NM202000019OtherPRESBYTERIAN COMMERCIAL
NM56185278Medicaid
NM202000019Medicaid
NM202000019OtherPRESBYTERIAN COMMERCIAL
TX174287602Medicaid