Provider Demographics
NPI:1346455672
Name:TANTIWONGKOSI, BUNDHIT (MD)
Entity Type:Individual
Prefix:DR
First Name:BUNDHIT
Middle Name:
Last Name:TANTIWONGKOSI
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 1:7400 MERTON MINTER ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4404
Mailing Address - Country:US
Mailing Address - Phone:210-617-5300
Mailing Address - Fax:
Practice Address - Street 1:7400 MERTON MINTER ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-617-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57-009559390200000X
CAA1034952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1034950Medicaid
CAWA103495AMedicare PIN
CA0A1034950Medicaid