Healthcare Provider Details

I. General information

NPI: 1821191107
Provider Name (Legal Business Name): SOMPORN PUANGSUVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W 12TH ST
CARUTHERSVILLE MO
63830-1890
US

IV. Provider business mailing address

PO BOX1155 418 WARD AVENUE
CARUTHERSVILLE MO
63830
US

V. Phone/Fax

Practice location:
  • Phone: 573-333-1124
  • Fax: 573-333-1124
Mailing address:
  • Phone: 573-333-0156
  • Fax: 573-333-0156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR7161
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: