MEDICARE: PUNYADECH PHOTANGTHAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	211187	NY

General Provider Information

NPI Number	:	1083700926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PUNYADECH PHOTANGTHAM MD

Provider Business Mailing Address
First Line	:	125 W 56TH ST
Second Line	:	#2B
City	:	NEW YORK
State	:	NY
Zip	:	10019-3807
Country	:	US
Telephone Number	:	212-247-7039
Fax Number	:	646-791-0402

Provider Business Practice Location Address
First Line	:	3875 BROADWAY
Second Line	:	UNIT B
City	:	NEW YORK
State	:	NY
Zip	:	10032-1567
Country	:	US
Telephone Number	:	212-543-3110
Fax Number	:	212-543-3111

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	12/02/2015

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