Provider Demographics
NPI:1306067392
Name:NIYAKORN, SUJITTRA (MD)
Entity type:Individual
Prefix:
First Name:SUJITTRA
Middle Name:
Last Name:NIYAKORN
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 1:1255 S MICHIGAN AVE APT 3006
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3317
Mailing Address - Country:US
Mailing Address - Phone:312-330-6770
Mailing Address - Fax:
Practice Address - Street 1:4022 HOHMAN AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46327-1239
Practice Address - Country:US
Practice Address - Phone:219-937-3300
Practice Address - Fax:219-931-0299
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6544207Q00000X
IN01067615207Q00000X
IL036-132572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine