Provider Demographics
NPI:1104930817
Name:SUKONTASUP, NUTAPORN (OD)
Entity type:Individual
Prefix:DR
First Name:NUTAPORN
Middle Name:
Last Name:SUKONTASUP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:
Other - Last Name:SUKONTASUP
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8315 ACADEMY RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6687
Mailing Address - Country:US
Mailing Address - Phone:443-804-1173
Mailing Address - Fax:
Practice Address - Street 1:8115 MAPLE LAWN BLVD
Practice Address - Street 2:SUITE 135
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2681
Practice Address - Country:US
Practice Address - Phone:443-804-1173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2017-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11431664OtherCAQH
11431664OtherCAQH