Provider Demographics
NPI:1023038353
Name:CHAMNONGCHAREONWONG, THAVATCHAI (DO)
Entity Type:Individual
Prefix:
First Name:THAVATCHAI
Middle Name:
Last Name:CHAMNONGCHAREONWONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:CHAI
Other - Middle Name:
Other - Last Name:CHAMNONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 242848
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-2848
Mailing Address - Country:US
Mailing Address - Phone:334-270-9914
Mailing Address - Fax:334-270-3195
Practice Address - Street 1:8300 CROSSLAND LOOP
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-8482
Practice Address - Country:US
Practice Address - Phone:334-239-8939
Practice Address - Fax:334-239-8918
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD0625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G87480Medicare UPIN
AL51556625Medicare ID - Type Unspecified