Provider Demographics
NPI:1174592950
Name:MONGKOLRATTANOTHAI, KANOKPORN (MD)
Entity type:Individual
Prefix:
First Name:KANOKPORN
Middle Name:
Last Name:MONGKOLRATTANOTHAI
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 1:4650 W SUNSET BLVD
Mailing Address - Street 2:MAILSTOP # 51
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6062
Mailing Address - Country:US
Mailing Address - Phone:323-361-8736
Mailing Address - Fax:323-361-1183
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MAILSTOP # 51
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-8736
Practice Address - Fax:323-361-1183
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112843208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07215036OtherBCBS
IL036112843Medicaid
IL036112843Medicaid