Healthcare Provider Details

I. General information

NPI: 1053304428
Provider Name (Legal Business Name): SOMNUK POW-ANPONGKUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 OCILLA RD
DOUGLAS GA
31533-2207
US

IV. Provider business mailing address

1101 OCILLA RD
DOUGLAS GA
31533-2207
US

V. Phone/Fax

Practice location:
  • Phone: 912-384-1900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number029756
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: