Provider Demographics
NPI:1477696284
Name:PHOMAKAY, CHANSAMONE M (MD)
Entity Type:Individual
Prefix:
First Name:CHANSAMONE
Middle Name:M
Last Name:PHOMAKAY
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:PO BOX 402319
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2319
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:709-709-7053
Practice Address - Street 1:4700 KELLEY HWY
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-5024
Practice Address - Country:US
Practice Address - Phone:479-573-7990
Practice Address - Fax:479-573-7991
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE-6214207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200232040AMedicaid
AR178879001Medicaid
AR5H937Medicare PIN
440110801Medicare ID - Type UnspecifiedARKANSAS MEDICAID RX #