Provider Demographics
NPI:1366430340
Name:SOONATTRAKUL, WUTHISAK
Entity type:Individual
Prefix:
First Name:WUTHISAK
Middle Name:
Last Name:SOONATTRAKUL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-2041
Mailing Address - Country:US
Mailing Address - Phone:573-888-1137
Mailing Address - Fax:573-888-0920
Practice Address - Street 1:105 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2041
Practice Address - Country:US
Practice Address - Phone:573-888-1137
Practice Address - Fax:573-888-0920
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA27279Medicare UPIN