Provider Demographics
NPI:1801054838
Name:PONGRUANGPORN, MAKHAWADEE (MD)
Entity type:Individual
Prefix:DR
First Name:MAKHAWADEE
Middle Name:
Last Name:PONGRUANGPORN
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4950 NORTON HEALTHCARE BLVD
Practice Address - Street 2:STE.303
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2845
Practice Address - Country:US
Practice Address - Phone:502-394-6470
Practice Address - Fax:502-394-6477
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012012189208M00000X
KY48026207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100361830Medicaid
KY7100361830Medicaid
KYK189220Medicare PIN