Provider Demographics
NPI:1750585170
Name:PHONCHAROENSRI, DITTANA (MD)
Entity type:Individual
Prefix:MR
First Name:DITTANA
Middle Name:
Last Name:PHONCHAROENSRI
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-893-3180
Mailing Address - Fax:336-893-3189
Practice Address - Street 1:152 E KINDERTON WAY STE 101
Practice Address - Street 2:
Practice Address - City:BERMUDA RUN
Practice Address - State:NC
Practice Address - Zip Code:27006-7351
Practice Address - Country:US
Practice Address - Phone:336-893-3180
Practice Address - Fax:336-893-3189
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013007842084S0012X
MS20635207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1750585170Medicaid
NCNCC681AMedicare PIN