Healthcare Provider Details

I. General information

NPI: 1013578350
Provider Name (Legal Business Name): POEMLARP MEKRAKSAKIT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

IV. Provider business mailing address

770 W GRANADA BLVD STE 101
ORMOND BEACH FL
32174-5179
US

V. Phone/Fax

Practice location:
  • Phone: 507-284-2511
  • Fax:
Mailing address:
  • Phone: 386-231-4746
  • Fax: 386-368-8927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number70811
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: