Healthcare Provider Details

I. General information

NPI: 1063604726
Provider Name (Legal Business Name): KANTIMA PHISITKUL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 STONE PARK BLVD
SIOUX CITY IA
51104-3734
US

IV. Provider business mailing address

2720 STONE PARK BLVD
SIOUX CITY IA
51104-3734
US

V. Phone/Fax

Practice location:
  • Phone: 712-279-3500
  • Fax: 712-279-3640
Mailing address:
  • Phone: 712-279-3500
  • Fax: 712-279-3640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number38776
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP1-0024170
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number38776
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: