Provider Demographics
NPI:1225281330
Name:HOMSOMBATH, BOUNTHAVY (MD)
Entity Type:Individual
Prefix:
First Name:BOUNTHAVY
Middle Name:
Last Name:HOMSOMBATH
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:PO BOX 3726
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3726
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:888-745-3917
Practice Address - Street 1:3675 J DEWEY GRAY CIR
Practice Address - Street 2:SUITE 300
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1868
Practice Address - Country:US
Practice Address - Phone:706-863-9595
Practice Address - Fax:888-745-3917
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA68031208600000X
CODR.00558392086S0102X
FL1174012086S0102X
MS228742086S0102X
SCMD355252086S0102X
TNMD00000638632086S0102X
TXQ60302086S0102X
GA0680312086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery