Individual
NIRANAT DEJTIRANUKUL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
800 E LOCUST ST, OLNEY, IL 62450-2553
(618) 395-7340
Mailing address
PO BOX 97, OLNEY, IL 62450-0097
(618) 395-7340
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
036-050750
IL
207YX0602X
Otolaryngic Allergy Physician
036-050750
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036050750
—
IL
01
—
08022315
BLUE CROSS/BLUE SHIELD
IL
01
—
216183
MEDICARE PTAN
—
Enumeration date
03/12/2007
Last updated
10/28/2011
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