MEDICARE: NATHAN BOUNYONG DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036.161773	IL

General Provider Information

NPI Number	:	1114580115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN BOUNYONG DO

Provider Business Mailing Address
First Line	:	5145 N CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3687
Country	:	US
Telephone Number	:	773-989-3808
Fax Number	:

Provider Business Practice Location Address
First Line	:	5145 N CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-3687
Country	:	US
Telephone Number	:	773-989-3808
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2019
Last Update Date	:	09/07/2022

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