Healthcare Provider Details

I. General information

NPI: 1861692642
Provider Name (Legal Business Name): SOMBAT MUENGTAWEEPONGSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 VISTA AVE SUITE 303
SAINT LOUIS MO
63110-2540
US

IV. Provider business mailing address

1438 S GRAND BLVD
SAINT LOUIS MO
63104-1027
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6082
  • Fax: 314-977-6086
Mailing address:
  • Phone: 314-977-4866
  • Fax: 314-977-4876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2005018787
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: