Healthcare Provider Details

I. General information

NPI: 1407888977
Provider Name (Legal Business Name): SURACHAT CHATKUPT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4643B WAIMEA CANYON DRIVE
WAIMEA HI
96796
US

IV. Provider business mailing address

PO BOX 669
WAIMEA HI
96796-0669
US

V. Phone/Fax

Practice location:
  • Phone: 808-338-8311
  • Fax: 808-338-0225
Mailing address:
  • Phone: 808-338-8311
  • Fax: 808-338-0225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD-12678
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: