Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 02005485A | IN |
NPI | 1003356684 |
---|---|
Provider Name | Dr. Don Vongviphut |
First Address | Torrance, CA 90505-4312 |
Second Address | Joint Base Mcguire-Dix-Lakehurst, NJ 08641 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/03/2017 |
Last Update Date | 29/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02005485A | INDIANA STATE MEDICAL LICENSE (01) | IN |