Trairud-Jack Watanachaiyot, D.P.T.

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

070-025183 Issued in IL

Practice address

4700 Gilbert Ave Ste 43a
Western Springs, IL 60558-1670

Phone

(708) 783-1044

Fax

(708) 783-1048

NPI assigned

Dec 9, 2013

Reactivated

Sep 23, 2022

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1386547200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1663891200000",
    "number": "1811328461",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "600 OAKMONT LN STE 600C",
            "city": "WESTMONT",
            "state": "IL",
            "postal_code": "605595548",
            "telephone_number": "630-575-6200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4700 GILBERT AVE STE 43A",
            "city": "WESTERN SPRINGS",
            "state": "IL",
            "postal_code": "605581670",
            "telephone_number": "708-783-1044",
            "fax_number": "708-783-1048"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WATANACHAIYOT",
        "first_name": "TRAIRUD-JACK",
        "name_prefix": "Mr.",
        "credential": "D.P.T.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-12-09",
        "last_updated": "2022-09-23",
        "certification_date": "2022-09-23",
        "deactivation_date": "2022-06-02",
        "reactivation_date": "2022-09-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "NY",
            "license": "29013",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "IL",
            "license": "070-025183",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physical Therapist in Western Springs, IL
• Providers in Western Springs, IL by specialty
• Physical Therapist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 23, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.