Provider Demographics
NPI:1194009415
Name:MONGKOLSMAI, CHALERMLARP (MD)
Entity Type:Individual
Prefix:MRS
First Name:CHALERMLARP
Middle Name:
Last Name:MONGKOLSMAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 BERRYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2448
Mailing Address - Country:US
Mailing Address - Phone:309-662-2032
Mailing Address - Fax:
Practice Address - Street 1:2206 BERRYWOOD LN
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2448
Practice Address - Country:US
Practice Address - Phone:309-662-2032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360598052080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD15849Medicare UPIN