Provider Demographics
NPI:1386644417
Name:SUKACHEVIN, CHULACHAK JON (MD)
Entity type:Individual
Prefix:
First Name:CHULACHAK
Middle Name:JON
Last Name:SUKACHEVIN
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 1:411 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-2037
Mailing Address - Country:US
Mailing Address - Phone:360-834-2863
Mailing Address - Fax:360-834-0160
Practice Address - Street 1:411 NE 6TH AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2037
Practice Address - Country:US
Practice Address - Phone:360-834-2863
Practice Address - Fax:360-834-0160
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054571207Q00000X
ORMD15286207Q00000X
WAMD 60173771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H01047Medicare UPIN
003856A74Medicare ID - Type Unspecified
WAG8895269Medicare Oscar/Certification