Healthcare Provider Details

I. General information

NPI: 1639268295
Provider Name (Legal Business Name): PONGSAK HUANGTHAISONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLARKSON AVE R BUILDING , 5TH FLOOR
BROOKLYN NY
11203-2054
US

IV. Provider business mailing address

451 CLARKSON AVE R BUILDING , 5TH FLOOR
BROOKLYN NY
11203-2054
US

V. Phone/Fax

Practice location:
  • Phone: 718-245-2728
  • Fax: 718-245-3254
Mailing address:
  • Phone: 718-245-2728
  • Fax: 718-245-3254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number269832
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: