Provider Demographics
NPI:1104826916
Name:SANGCHOMPUPHEN, TONY (MD)
Entity Type:Individual
Prefix:DR
First Name:TONY
Middle Name:
Last Name:SANGCHOMPUPHEN
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 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2045 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5437
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350817432085R0202X
MO20060022502085R0202X
CO473262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2401056Medicaid
KY64063977Medicaid
CO26457733Medicaid
CO019469OtherKAISER COMMERCIAL NUMBER
OH300136030OtherSOR RR MDCR PIN NUMBER
OHP00202433OtherSOM RR MDCR PIN NUMBER
OH300136030OtherSOR RR MDCR PIN NUMBER
CO26457733Medicaid
COCO303734Medicare PIN
OH4096671Medicare PIN
KY64063977Medicaid
OH4096673Medicare PIN