Healthcare Provider Details

I. General information

NPI: 1518306570
Provider Name (Legal Business Name): YUTTANA CHAWENGSUB M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2013
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MERCY DR
COUNCIL BLUFFS IA
51503-3128
US

IV. Provider business mailing address

800 MERCY DR
COUNCIL BLUFFS IA
51503-3128
US

V. Phone/Fax

Practice location:
  • Phone: 855-524-4001
  • Fax: 712-325-2499
Mailing address:
  • Phone: 855-524-4001
  • Fax: 712-325-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125063902
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD61203457
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-40350
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2022-1256
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberCP1338
License Number StateNE
# 6
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD-43157
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: