Provider Demographics
NPI:1003356684
Name:VONGVIPHUT, DON (DO)
Entity Type:Individual
Prefix:DR
First Name:DON
Middle Name:
Last Name:VONGVIPHUT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5109 BINDEWALD RD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4312
Mailing Address - Country:US
Mailing Address - Phone:650-714-5919
Mailing Address - Fax:
Practice Address - Street 1:3458 NEELY RD
Practice Address - Street 2:FLIGHT MEDICINE CLINIC
Practice Address - City:JOINT BASE MCGUIRE-DIX-LAKEHURST
Practice Address - State:NJ
Practice Address - Zip Code:08641
Practice Address - Country:US
Practice Address - Phone:609-754-9080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005485A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02005485AOtherINDIANA STATE MEDICAL LICENSE