Healthcare Provider Details

I. General information

NPI: 1124638531
Provider Name (Legal Business Name): ANURUT HUNTRAKUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2020
Last Update Date: 08/01/2020
Certification Date: 08/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

1016 CHESTER RD APT B11
LANSING MI
48912-4835
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 517-940-0577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351047285
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: