MEDICARE: KHONGRUK WONGKITTIROCH D.O.

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	207N00000X	Dermatology Physician	OS11792	FL
2	207NI0002X	Clinical & Laboratory Dermatological Immunology Physician	OS11792	FL
3	207ND0900X	Dermatopathology Physician	OS11792	FL
4	207ND0101X	MOHS-Micrographic Surgery Physician	OS11792	FL
5	207NP0225X	Pediatric Dermatology Physician	OS11792	FL
6	207NS0135X	Procedural Dermatology Physician	OS11792	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	28528	OTHER	FL	BLUE CROSS BLUE SHIELD OF FLORIDA
2	261637814	OTHER	FL	MULTI PLAN
3	317129	OTHER	FL	AVMED
4	261637814	OTHER	FL	UNITED HEALTHCARE
5	6375863	OTHER	FL	CIGNA

General Provider Information

NPI Number	:	1205003068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHONGRUK WONGKITTIROCH D.O.

Provider Business Mailing Address
First Line	:	2838 E OAKLAND PARK BLVD
Second Line	:	STE 201
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1814
Country	:	US
Telephone Number	:	954-564-0040
Fax Number	:

Provider Business Practice Location Address
First Line	:	2838 E OAKLAND PARK BLVD
Second Line	:	STE 201
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1814
Country	:	US
Telephone Number	:	954-564-0040
Fax Number	:	954-564-0048

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

Provider Enumeration Date	:	05/12/2008
Last Update Date	:	12/18/2014

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