Healthcare Provider Details

I. General information

NPI: 1467574467
Provider Name (Legal Business Name): KONGKRIT CHAIYASATE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36800 WOODWARD AVE STE 112
BLOOMFIELD HILLS MI
48304-0916
US

IV. Provider business mailing address

125 BRIDGEVIEW DR
BLOOMFIELD HILLS MI
48304-2425
US

V. Phone/Fax

Practice location:
  • Phone: 947-274-8300
  • Fax:
Mailing address:
  • Phone: 248-890-2515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301078734
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: