Healthcare Provider Details

I. General information

NPI: 1275996365
Provider Name (Legal Business Name): CHAYAKRIT KRITTANAWONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1256 N EISENHOWER DR
BECKLEY WV
25801-3120
US

IV. Provider business mailing address

1256 N EISENHOWER DR
BECKLEY WV
25801-3120
US

V. Phone/Fax

Practice location:
  • Phone: 304-254-2415
  • Fax: 304-254-2415
Mailing address:
  • Phone: 304-254-2415
  • Fax: 304-254-2415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number32509
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number32509
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: