Healthcare Provider Details

I. General information

NPI: 1407821077
Provider Name (Legal Business Name): KEATTIYOAT WATTANAKIT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 N KNOXVILLE AVE
PEORIA IL
61614
US

IV. Provider business mailing address

PO BOX 9382
PEORIA IL
61612-9382
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-4410
  • Fax:
Mailing address:
  • Phone: 309-691-4410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036126173
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036126173
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number036126173
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: