Healthcare Provider Details

I. General information

NPI: 1629768817
Provider Name (Legal Business Name): SORAWIT ONGSUPANKUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date: 12/18/2023
Reactivation Date: 01/02/2024

III. Provider practice location address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

IV. Provider business mailing address

PO BOX 860912
MINNEAPOLIS MN
55486-0912
US

V. Phone/Fax

Practice location:
  • Phone: 507-284-2511
  • Fax:
Mailing address:
  • Phone: 507-284-2511
  • Fax: 507-284-0702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number81941
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: