Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2084N0400X | Neurologist | A120867 | CA |
N | 2084N0600X | Clinical Neurophysiologist | A120867 | CA |
NPI | 1003187808 |
---|---|
Provider Name | Justin Cheongsiatmoy |
First Address | Colorado Springs, CO 80903-1928 |
Second Address | Colorado Springs, CO 80903-1928 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2012 |
Last Update Date | 18/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A120867 | MEDICAL LICENSE (01) | CA |