Provider Demographics
NPI:1629380159
Name:MAHATANAN, RATTANAPORN (MD)
Entity type:Individual
Prefix:DR
First Name:RATTANAPORN
Middle Name:
Last Name:MAHATANAN
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 1:248 PLEASANT ST STE 103
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2588
Mailing Address - Country:US
Mailing Address - Phone:603-230-1939
Mailing Address - Fax:603-227-7568
Practice Address - Street 1:248 PLEASANT ST STE 103
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2588
Practice Address - Country:US
Practice Address - Phone:603-230-1939
Practice Address - Fax:603-227-7568
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH24186207R00000X, 207RI0200X
MEMD19500207R00000X
NH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1629380159Medicaid