Basic Information
| Provider Information | |||||||||
| NPI: | 1528249687 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUKSANONG AND SUKSANONG MDS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1945 | ||||||||
| Address2: | |||||||||
| City: | PALM HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346821945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277711300 | ||||||||
| FaxNumber: | 7277812300 | ||||||||
| Practice Location | |||||||||
| Address1: | 1752 MLK JR ST N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337044206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278237224 | ||||||||
| FaxNumber: | 7274899486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | SUKSANONG | ||||||||
| AuthorizedOfficialFirstName: | MINGQUAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 7278237224 | ||||||||
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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 | 207RI0200X | ME31666 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | DQ8992 | 01 | FL | RR MEDICARE | OTHER |