Healthcare Provider Details

I. General information

NPI: 1699818658
Provider Name (Legal Business Name): CHOTCHAI SRISURO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 COUCH AVE SUITE 287
SAINT LOUIS MO
63122-5561
US

IV. Provider business mailing address

533 COUCH AVE SUITE 287
SAINT LOUIS MO
63122-5561
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-9144
  • Fax: 314-821-8019
Mailing address:
  • Phone: 314-821-9144
  • Fax: 314-821-8019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number33186
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: