Provider Demographics
NPI:1134284615
Name:CHUMNANVECH, THEERAYUT (MD)
Entity Type:Individual
Prefix:
First Name:THEERAYUT
Middle Name:
Last Name:CHUMNANVECH
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 1:30 STEVENS STREET
Mailing Address - Street 2:SUITE H
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850
Mailing Address - Country:US
Mailing Address - Phone:203-299-1699
Mailing Address - Fax:203-299-1579
Practice Address - Street 1:30 STEVENS STREET
Practice Address - Street 2:SUITE H
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850
Practice Address - Country:US
Practice Address - Phone:203-299-1699
Practice Address - Fax:203-299-1579
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017469208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1174697Medicaid
B38632Medicare UPIN