Healthcare Provider Details

I. General information

NPI: 1225061880
Provider Name (Legal Business Name): WITTAWAT KASAYAPANAND M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 S FRANKLIN ST
WILKES BARRE PA
18702-3808
US

IV. Provider business mailing address

29 SAND ST
PITTSTON PA
18640-2609
US

V. Phone/Fax

Practice location:
  • Phone: 570-825-6425
  • Fax: 570-829-3337
Mailing address:
  • Phone: 570-332-5348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD071545L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMD071545L
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerPHYSICIAN LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: