Provider Demographics
NPI:1457451262
Name:VANSOMPHONE, BOUNGKHONG DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:BOUNGKHONG
Middle Name:DAVID
Last Name:VANSOMPHONE
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 35984
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5984
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:702-453-5741
Practice Address - Street 1:5375 S FORT APACHE RD
Practice Address - Street 2:STE# 101
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-7623
Practice Address - Country:US
Practice Address - Phone:702-597-1597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018399Medicaid
MT12431OtherLIC
CAC53921OtherLIC
CODR48601OtherLIC
CAC53921OtherLIC
NVH25909Medicare UPIN
NVV104613Medicare PIN