Provider Demographics
NPI:1275578387
Name:VONGKASEMSIRI, SUNAN (MD)
Entity Type:Individual
Prefix:
First Name:SUNAN
Middle Name:
Last Name:VONGKASEMSIRI
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 596
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37879-0596
Mailing Address - Country:US
Mailing Address - Phone:606-248-1320
Mailing Address - Fax:606-248-1518
Practice Address - Street 1:1850 OLD KNOXVILLE RD
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37879-3625
Practice Address - Country:US
Practice Address - Phone:426-626-4211
Practice Address - Fax:606-248-1518
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000149042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3036248Medicaid
TN3036248Medicaid
TN3700491Medicare ID - Type Unspecified