Healthcare Provider Details

I. General information

NPI: 1205852514
Provider Name (Legal Business Name): DECHA ENKVETCHAKUL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL 5TH FLOOR, SUITE C
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8126
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-7603
  • Fax: 314-361-4197
Mailing address:
  • Phone: 314-362-7603
  • Fax: 314-361-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number103678
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: