Basic Information
| Provider Information | |||||||||
| NPI: | 1205090297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHISITKUL | ||||||||
| FirstName: | PHINIT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2730 PIERCE ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511043796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122248677 | ||||||||
| FaxNumber: | 7122771662 | ||||||||
| Practice Location | |||||||||
| Address1: | 2730 PIERCE ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511043796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122248677 | ||||||||
| FaxNumber: | 7122771662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 12/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 36706 | IA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0004X | 36706 | IA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
No ID Information.