Provider Demographics
NPI:1780429787
Name:HOLSAKUL, KORNKAMOL (MD)
Entity type:Individual
Prefix:MISS
First Name:KORNKAMOL
Middle Name:
Last Name:HOLSAKUL
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 1:18 S KINGSHIGHWAY BLVD APT 15S
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1331
Mailing Address - Country:US
Mailing Address - Phone:314-574-7970
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1081
Practice Address - Country:US
Practice Address - Phone:314-362-2184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024019900208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics