Provider Demographics
NPI:1386727642
Name:SETHAKORN, AMNUAY (MD)
Entity type:Individual
Prefix:MR
First Name:AMNUAY
Middle Name:
Last Name:SETHAKORN
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 527
Mailing Address - Street 2:4 DOCTORS PARK
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936
Mailing Address - Country:US
Mailing Address - Phone:217-784-8919
Mailing Address - Fax:
Practice Address - Street 1:4 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936
Practice Address - Country:US
Practice Address - Phone:217-784-8919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
775440Medicare ID - Type Unspecified
C38950Medicare UPIN