Provider Demographics
NPI:1740272236
Name:PITIRANGGON, PONGSTORN (MD)
Entity type:Individual
Prefix:DR
First Name:PONGSTORN
Middle Name:
Last Name:PITIRANGGON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 S DARGAN ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2552
Mailing Address - Country:US
Mailing Address - Phone:843-669-5956
Mailing Address - Fax:843-669-2019
Practice Address - Street 1:514 S DARGAN ST
Practice Address - Street 2:SUITE H
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2552
Practice Address - Country:US
Practice Address - Phone:843-669-5956
Practice Address - Fax:843-669-2019
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20141174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT42219Medicaid
SCT42219Medicaid
SCG742657758Medicare PIN