MEDICARE: PANYAMOL PAM KITTIPONGDAJA DO

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	OS018946	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861821589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PANYAMOL PAM KITTIPONGDAJA DO

Provider Business Mailing Address
First Line	:	151 SOUTHHALL LN STE 300
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-7172
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 OFFICE CENTER DR STE 190-195
Second Line	:
City	:	FORT WASHINGTON
State	:	PA
Zip	:	19034-3220
Country	:	US
Telephone Number	:	215-836-7900
Fax Number	:

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

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	02/13/2018

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