Provider Demographics
NPI:1306259809
Name:CHAIWATCHARAYUT, WIKROM (MD)
Entity type:Individual
Prefix:
First Name:WIKROM
Middle Name:
Last Name:CHAIWATCHARAYUT
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 1:1843 QUIET CV
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3857
Mailing Address - Country:US
Mailing Address - Phone:910-483-8080
Mailing Address - Fax:
Practice Address - Street 1:200 S WELLS RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1377
Practice Address - Country:US
Practice Address - Phone:805-647-6322
Practice Address - Fax:805-647-7164
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA144707207R00000X
NC2021-02077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine