Healthcare Provider Details

I. General information

NPI: 1174634927
Provider Name (Legal Business Name): SOMPONGSE - ANGSPATT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NONE NONE N/A

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 VICTORIA DR
OAK FOREST IL
60452-2134
US

IV. Provider business mailing address

3515 ITHACA RD
OLYMPIA FIELDS IL
60461-1343
US

V. Phone/Fax

Practice location:
  • Phone: 708-687-7550
  • Fax: 708-687-7552
Mailing address:
  • Phone: 708-687-7550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: