Healthcare Provider Details

I. General information

NPI: 1699951558
Provider Name (Legal Business Name): KOBKIT PUTRAKUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MARIE LANGDON DR
MANCHESTER KY
40962
US

IV. Provider business mailing address

600 GREENWAY DR
LONDON KY
40741-1629
US

V. Phone/Fax

Practice location:
  • Phone: 606-598-5104
  • Fax: 606-983-7252
Mailing address:
  • Phone: 606-401-5490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number41570
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTP656
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: