Provider Demographics
NPI:1952720872
Name:KANCHONGKITTIPHON, WATCHAROOT
Entity Type:Individual
Prefix:
First Name:WATCHAROOT
Middle Name:
Last Name:KANCHONGKITTIPHON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LAFEYETTE PLAISANCE ST
Mailing Address - Street 2:APT 1103
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207
Mailing Address - Country:US
Mailing Address - Phone:857-200-7407
Mailing Address - Fax:
Practice Address - Street 1:3901 BEAUBIEN BLVD.
Practice Address - Street 2:CHILDREN'S HOSPITAL OF MICHIGAN
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-1892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program