Individual
KHONGRUK WONGKITTIROCH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
2838 E OAKLAND PARK BLVD, STE 201, FORT LAUDERDALE, FL 33306-1814
(954) 564-0040
(954) 564-0048
Mailing address
2838 E OAKLAND PARK BLVD, STE 201, FORT LAUDERDALE, FL 33306-1814
(954) 564-0040
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
OS11792
FL
207ND0101X
MOHS-Micrographic Surgery Physician
OS11792
FL
207ND0900X
Dermatopathology Physician
OS11792
FL
207NI0002X
Clinical & Laboratory Dermatological Immunology Physician
OS11792
FL
207NP0225X
Pediatric Dermatology Physician
OS11792
FL
207NS0135X
Procedural Dermatology Physician
OS11792
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
261637814
MULTI PLAN
FL
01
—
28528
BLUE CROSS BLUE SHIELD OF FLORIDA
FL
01
—
317129
AVMED
FL
01
—
6375863
CIGNA
FL
Enumeration date
05/12/2008
Last updated
12/18/2014
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