Healthcare Provider Details

I. General information

NPI: 1508801366
Provider Name (Legal Business Name): NORRAPOL WATTANASUWAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 JEFFERSON ST
LAUREL MS
39440-4354
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-2863
  • Fax: 601-649-9479
Mailing address:
  • Phone: 601-425-7550
  • Fax: 601-399-6184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number18611
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number18611
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: