Provider Demographics
NPI:1932202744
Name:SAKDISRI, SONGYOTH (MD)
Entity Type:Individual
Prefix:DR
First Name:SONGYOTH
Middle Name:
Last Name:SAKDISRI
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 1:2001 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62205-1803
Mailing Address - Country:US
Mailing Address - Phone:618-271-9191
Mailing Address - Fax:618-271-9617
Practice Address - Street 1:2001 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-1803
Practice Address - Country:US
Practice Address - Phone:618-271-9191
Practice Address - Fax:618-271-9617
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036148571207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048571Medicaid
IL036048571Medicaid
ILB26112Medicare UPIN