Healthcare Provider Details

I. General information

NPI: 1245315365
Provider Name (Legal Business Name): SOMCHAI LAOWATTANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

IV. Provider business mailing address

12632 S HARLEM AVE
PALOS HEIGHTS IL
60463-1428
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-5200
  • Fax: 414-259-0469
Mailing address:
  • Phone: 708-587-0000
  • Fax: 708-623-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036154960
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number52265-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: