Healthcare Provider Details

I. General information

NPI: 1386704989
Provider Name (Legal Business Name): SOMMAI BUNYAVANICH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 BEACH CHANNEL DR
ARVERNE NY
11692-1409
US

IV. Provider business mailing address

6200 BEACH CHANNEL DR
ARVERNE NY
11692-1409
US

V. Phone/Fax

Practice location:
  • Phone: 718-945-7150
  • Fax:
Mailing address:
  • Phone: 718-945-7150
  • Fax: 718-318-4809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number117347
License Number StateNY

VIII. Authorized Official

Name: DR. SOMMAI BUNYAVANICH
Title or Position: ATTENDING
Credential: M.D.
Phone: 718-945-7150