Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080N0001X | Neonatal-Perinatal Doctor | ME 80474 | FL |
NPI | 1023186467 |
---|---|
Provider Name | Phuket Tantivit |
First Address | Coral Gables, FL 33146-2423 |
Second Address | Coral Gables, FL 33146-2423 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
260 097 800 | (05) | FL |