Healthcare Provider Details

I. General information

NPI: 1801054838
Provider Name (Legal Business Name): MAKHAWADEE PONGRUANGPORN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 NORTON HEALTHCARE BLVD STE.303
LOUISVILLE KY
40241-2845
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-394-6470
  • Fax: 502-394-6477
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number48026
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2012012189
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: