Healthcare Provider Details

I. General information

NPI: 1639124530
Provider Name (Legal Business Name): CHANIKA PHORNPHUTKUL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

593 EDDY ST HASBRO 122
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-8361
  • Fax: 401-444-3288
Mailing address:
  • Phone: 401-444-8361
  • Fax: 401-444-3288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number10121
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207SG0202X
TaxonomyClinical Biochemical Genetics Physician
License NumberMD10121
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: