Basic Information
| Provider Information | |||||||||
| NPI: | 1114995958 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ISSARA I. AYUTHIA, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1331 | ||||||||
| Address2: | |||||||||
| City: | DODGE CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678011331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166856236 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 AVENUE A | ||||||||
| Address2: | |||||||||
| City: | DODGE CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678016508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202259050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | AYUTHIA | ||||||||
| AuthorizedOfficialFirstName: | ISSARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6202258437 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0102X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.