Basic Information
Provider Information | |||||||||
NPI: | 1023033834 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PIRIYAWAT | ||||||||
FirstName: | PAISITH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 440 RAYNOLDS ST # 51015 | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799051613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9152154480 | ||||||||
FaxNumber: | 9152155386 | ||||||||
Practice Location | |||||||||
Address1: | 4801 ALBERTA AVE | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799052707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9152155900 | ||||||||
FaxNumber: | 9152158615 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2006 | ||||||||
LastUpdateDate: | 01/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084V0102X | L1698 | TX | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2084A2900X | L1698 | TX | Y |   |   |   |   | 2084D0003X | L1698 | TX | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Diagnostic Neuroimaging | 2084N0400X | 35116 | SC | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | L1698 | TX | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 2005005294 | MO | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 351167 | 05 | SC |   | MEDICAID |