Provider Demographics
NPI:1982806329
Name:CHONGKRAIRATANAKUL, TEPSIRI (MD)
Entity Type:Individual
Prefix:DR
First Name:TEPSIRI
Middle Name:
Last Name:CHONGKRAIRATANAKUL
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 1:4225 EXECUTIVE SQ STE 450
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-8411
Mailing Address - Country:US
Mailing Address - Phone:858-810-8000
Mailing Address - Fax:858-268-1911
Practice Address - Street 1:8010 FROST ST STE 510
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-637-4700
Practice Address - Fax:858-637-4701
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC157995207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1982806329Medicaid
WIK400306684Medicare PIN