Healthcare Provider Details

I. General information

NPI: 1942362777
Provider Name (Legal Business Name): KONGSAK TANPHAICHITR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11115 NEW HALLS FERRY RD SUITE 102
FLORISSANT MO
63033-7613
US

IV. Provider business mailing address

11115 NEW HALLS FERRY RD SUITE 102
FLORISSANT MO
63033-7613
US

V. Phone/Fax

Practice location:
  • Phone: 314-839-4339
  • Fax: 314-839-0011
Mailing address:
  • Phone: 314-839-4339
  • Fax: 314-839-0011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number35104
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number35104
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: