Provider Demographics
NPI:1215905062
Name:AYUTHIA, ISSARA (MD)
Entity type:Individual
Prefix:
First Name:ISSARA
Middle Name:
Last Name:AYUTHIA
Suffix:
Gender:M
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 1331
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-1331
Mailing Address - Country:US
Mailing Address - Phone:316-685-6236
Mailing Address - Fax:
Practice Address - Street 1:3001 AVENUE A
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-6508
Practice Address - Country:US
Practice Address - Phone:620-225-8437
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-17419207ZP0102X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Not Answered207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS002902OtherBCBS
002902Medicare ID - Type Unspecified
KS002902OtherBCBS