Healthcare Provider Details

I. General information

NPI: 1669464269
Provider Name (Legal Business Name): CHANINTHORN SETABUTR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date: 03/25/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

605 W GIBSON ST
JASPER TX
75951-4909
US

IV. Provider business mailing address

605 W GIBSON ST
JASPER TX
75951-4909
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-3478
  • Fax: 409-383-1056
Mailing address:
  • Phone: 409-384-3478
  • Fax: 409-383-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG1273
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: