Provider Demographics
NPI:1992922942
Name:NIKOM UDOM MEDICAL CLINIC
Entity type:Organization
Organization Name:NIKOM UDOM MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIKOM
Authorized Official - Middle Name:
Authorized Official - Last Name:UDOMPHONKUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-846-3604
Mailing Address - Street 1:PO BOX 947
Mailing Address - Street 2:
Mailing Address - City:GRIDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95948-0947
Mailing Address - Country:US
Mailing Address - Phone:530-846-3604
Mailing Address - Fax:530-846-2108
Practice Address - Street 1:145 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GRIDLEY
Practice Address - State:CA
Practice Address - Zip Code:95948-0947
Practice Address - Country:US
Practice Address - Phone:530-846-3604
Practice Address - Fax:530-846-2108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34194207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A341940Medicaid
CAZZZ86416ZMedicare ID - Type Unspecified
CA00A341940Medicaid