Healthcare Provider Details

I. General information

NPI: 1558363713
Provider Name (Legal Business Name): POONPUTT CHOTIPRASIDHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 VALLEY VIEW DR
MOLINE IL
61265-6138
US

IV. Provider business mailing address

525 VALLEY VIEW DR
MOLINE IL
61265-6138
US

V. Phone/Fax

Practice location:
  • Phone: 309-601-2800
  • Fax: 309-601-2801
Mailing address:
  • Phone: 309-601-2800
  • Fax: 309-601-2801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036103123
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: