Healthcare Provider Details

I. General information

NPI: 1366186876
Provider Name (Legal Business Name): ROBERT CHANTHAVONGSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 READE PL
POUGHKEEPSIE NY
12601-3947
US

IV. Provider business mailing address

45 READE PL
POUGHKEEPSIE NY
12601-3947
US

V. Phone/Fax

Practice location:
  • Phone: 845-483-6299
  • Fax:
Mailing address:
  • Phone: 845-790-1301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number340641
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: