Healthcare Provider Details

I. General information

NPI: 1568469062
Provider Name (Legal Business Name): JIRAYOS CHINTANADILOK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4296 5TH AVE
MARIANNA FL
32446-2173
US

IV. Provider business mailing address

4296 5TH AVE
MARIANNA FL
32446-2173
US

V. Phone/Fax

Practice location:
  • Phone: 850-482-2061
  • Fax: 850-482-6617
Mailing address:
  • Phone: 850-482-2061
  • Fax: 850-482-6617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberARNP
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9101074
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME77246
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME77246
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME77246
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberARNP1903302
License Number StateFL
# 7
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME27861
License Number StateFL

VIII. Authorized Official

Name: JIRAYOS CHINTANADILOK
Title or Position: M.D. (OWNER)
Credential: M.D.
Phone: 850-482-2061