Provider Demographics
NPI:1194761858
Name:CHENG, SIRIDAO LAOHASATIT (MD)
Entity type:Individual
Prefix:
First Name:SIRIDAO
Middle Name:LAOHASATIT
Last Name:CHENG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:MOULTON
Mailing Address - State:AL
Mailing Address - Zip Code:35650-0340
Mailing Address - Country:US
Mailing Address - Phone:256-974-3390
Mailing Address - Fax:256-905-0261
Practice Address - Street 1:10939 AL HIGHWAY 157
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:AL
Practice Address - Zip Code:35650-1900
Practice Address - Country:US
Practice Address - Phone:256-974-3390
Practice Address - Fax:256-905-0261
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000206582080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL540003401Medicaid
AL540003994Medicaid
AL540003401Medicaid
AL01-3994Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC