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General NPI Number Information
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NPI Number | 1205245024
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Entity Type | Individual
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Provider Name | POOVASIT KLINOUBOL DPM
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Gender | Male
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Dates
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Enumeration Date | 08/06/2014
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Last Update Date | 12/23/2018
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Provider Practice Location Address
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Address Line | 12 NORTH SEVENTH AVENUE
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City | MOUNT VERNON
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State | NY
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Zip | 10550
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Country | US
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Telephone | 646-338-9832
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Fax |
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Provider Business Mailing Address
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Address Line | 40 E SIDNEY AVE APT 7E
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City | MOUNT VERNON
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State | NY
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Zip | 10550-1419
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Country | US
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Telephone | 646-338-9832
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 006854
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License Number State | NY
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