1003356684 NPI number — DR. DON VONGVIPHUT DO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003356684 NPI number — DR. DON VONGVIPHUT DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VONGVIPHUT
Provider First Name:
DON
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003356684
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5109 BINDEWALD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90505-4312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-714-5919
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3458 NEELY RD
Provider Second Line Business Practice Location Address:
FLIGHT MEDICINE CLINIC
Provider Business Practice Location Address City Name:
JOINT BASE MCGUIRE-DIX-LAKEHURST
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-754-9080
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  02005485A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02005485A . This is a "INDIANA STATE MEDICAL LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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