Healthcare Provider Details

I. General information

NPI: 1053496752
Provider Name (Legal Business Name): NIBONDH CHAIYUPATUMPA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 SCOTT ST
BALTIMORE MD
21230-2333
US

IV. Provider business mailing address

6628 HUNTERS WOOD CIR
BALTIMORE MD
21228-2527
US

V. Phone/Fax

Practice location:
  • Phone: 410-685-1982
  • Fax: 410-685-1374
Mailing address:
  • Phone: 410-788-3426
  • Fax: 410-788-3426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberD0018850
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: