Provider Demographics
NPI:1083721641
Name:PENGVANICH, CHAISAK (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAISAK
Middle Name:
Last Name:PENGVANICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40210-1745
Mailing Address - Country:US
Mailing Address - Phone:502-772-1822
Mailing Address - Fax:502-774-8464
Practice Address - Street 1:1607 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40210-1745
Practice Address - Country:US
Practice Address - Phone:502-772-1822
Practice Address - Fax:502-774-8464
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17517207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64175177Medicaid
KYC64838Medicare UPIN
KY1425801Medicare ID - Type Unspecified