Healthcare Provider Details

I. General information

NPI: 1811919871
Provider Name (Legal Business Name): PENPORN VONGSVIVUT RECK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 COLLEGE ST SE STE C
LACEY WA
98503-1014
US

IV. Provider business mailing address

345 COLLEGE ST SE SUITE C
LACEY WA
98503-1014
US

V. Phone/Fax

Practice location:
  • Phone: 360-456-3200
  • Fax: 360-456-3894
Mailing address:
  • Phone: 360-456-3200
  • Fax: 360-456-3894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberMD00049407
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD00049407
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: