Provider Demographics
NPI:1972358232
Name:PUCHONGMART, CHANOKPORN (MD)
Entity type:Individual
Prefix:DR
First Name:CHANOKPORN
Middle Name:
Last Name:PUCHONGMART
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 1:14461 JUDD ST
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-5054
Mailing Address - Country:US
Mailing Address - Phone:818-355-4493
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-6840
Practice Address - Fax:806-743-3143
Is Sole Proprietor?:No
Enumeration Date:2024-04-20
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program