Healthcare Provider Details

I. General information

NPI: 1679703045
Provider Name (Legal Business Name): PRABHAKORN KITBHOKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 PARK PL
MISHAWAKA IN
46545-3519
US

IV. Provider business mailing address

PO BOX 5909
PORTLAND OR
97228-5909
US

V. Phone/Fax

Practice location:
  • Phone: 574-273-6787
  • Fax: 574-968-7160
Mailing address:
  • Phone: 574-273-6767
  • Fax: 574-968-7160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01077845A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD211417
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number96918
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: