Healthcare Provider Details

I. General information

NPI: 1669854048
Provider Name (Legal Business Name): KRIS RUANGCHOTVIT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9929 REA RD STE 201
WAXHAW NC
28173-6439
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-1650
  • Fax: 704-316-1651
Mailing address:
  • Phone: 704-384-1261
  • Fax: 704-384-3145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMT209879
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2019-00957
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: