MEDICARE: DR. BOUNGKHONG DAVID VANSOMPHONE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	9448	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	12431	OTHER	MT	LIC
3	C53921	OTHER	CA	LIC
4	DR48601	OTHER	CO	LIC

General Provider Information

NPI Number	:	1457451262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BOUNGKHONG DAVID VANSOMPHONE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 35984
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89133-5984
Country	:	US
Telephone Number	:	702-453-3799
Fax Number	:	702-453-5741

Provider Business Practice Location Address
First Line	:	5375 S FORT APACHE RD
Second Line	:	STE# 101
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-7623
Country	:	US
Telephone Number	:	702-597-1597
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	12/23/2010

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