Basic Information
| Provider Information | |||||||||
| NPI: | 1972556256 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KULSAKDINUN | ||||||||
| FirstName: | CHAIYAPORN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | MT KISCO MEDICAL GROUP PC | ||||||||
| Address2: | 90 SOUTH BEDFORD ROAD | ||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105493412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142411050 | ||||||||
| FaxNumber: | 9142421516 | ||||||||
| Practice Location | |||||||||
| Address1: | MT KISCO MEDICAL GROUP PC | ||||||||
| Address2: | 90 SOUTH BEDFORD ROAD | ||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105493412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142411050 | ||||||||
| FaxNumber: | 9142421516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 10/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 211185 | NY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0004X | 211185 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 133544120 | 01 | NY | TAX ID | OTHER | 01978349 | 05 | NY | MEDICAID |