Provider Demographics
NPI:1538156781
Name:SATHISSARAT, VORAPHOT (MD)
Entity type:Individual
Prefix:DR
First Name:VORAPHOT
Middle Name:
Last Name:SATHISSARAT
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 1:2000 GLENWOOD AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435
Mailing Address - Country:US
Mailing Address - Phone:815-741-1212
Mailing Address - Fax:815-741-0707
Practice Address - Street 1:2000 GLENWOOD AVE
Practice Address - Street 2:STE 100
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-741-1212
Practice Address - Fax:815-741-0707
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036046328207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036046328Medicaid
09932417OtherBCBS
K27284Medicare ID - Type UnspecifiedINDIVIDUAL
213511Medicare ID - Type Unspecified
ILP05625Medicare ID - Type Unspecified
C45403Medicare UPIN