Healthcare Provider Details

I. General information

NPI: 1457451262
Provider Name (Legal Business Name): BOUNGKHONG DAVID VANSOMPHONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 12/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5375 S FORT APACHE RD STE# 101
LAS VEGAS NV
89148-7623
US

IV. Provider business mailing address

PO BOX 35984
LAS VEGAS NV
89133-5984
US

V. Phone/Fax

Practice location:
  • Phone: 702-597-1597
  • Fax:
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9448
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: