Healthcare Provider Details

I. General information

NPI: 1992955397
Provider Name (Legal Business Name): NIPAPAT VISAVACHAIPAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1841 S CALUMET AVE APT# 809
CHICAGO IL
60616-4627
US

IV. Provider business mailing address

1841 S CALUMET AVE APT# 809
CHICAGO IL
60616-4627
US

V. Phone/Fax

Practice location:
  • Phone: 312-799-1808
  • Fax:
Mailing address:
  • Phone: 312-799-1808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125053293
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: