Provider Demographics
NPI:1679703045
Name:KITBHOKA, PRABHAKORN (MD)
Entity type:Individual
Prefix:DR
First Name:PRABHAKORN
Middle Name:
Last Name:KITBHOKA
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 5909
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-5909
Mailing Address - Country:US
Mailing Address - Phone:574-273-6767
Mailing Address - Fax:574-968-7160
Practice Address - Street 1:710 PARK PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3519
Practice Address - Country:US
Practice Address - Phone:574-273-6787
Practice Address - Fax:574-968-7160
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077845A207RN0300X
ORMD211417207RN0300X
GA96918207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology