Healthcare Provider Details

I. General information

NPI: 1972679611
Provider Name (Legal Business Name): CHIN THAPVONGSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1269 GRAND CONCOURSE
BRONX NY
10452
US

IV. Provider business mailing address

28 BIRCHDALE LANE
PORT WASHINGTON NY
10050-4502
US

V. Phone/Fax

Practice location:
  • Phone: 718-293-3424
  • Fax: 718-293-3424
Mailing address:
  • Phone: 516-627-2505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number133396
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: