Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0202X | Pediatric Cardiologist | 036059805 | IL |
NPI | 1194009415 |
---|---|
Provider Name | Mrs. Chalermlarp Mongkolsmai |
First Address | Bloomington, IL 61704-2448 |
Second Address | Bloomington, IL 61704-2448 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/10/2011 |
Last Update Date | 05/10/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D15849 | (02) | IL |