Provider Demographics
NPI:1497792329
Name:LOTONGKHUM, VICHAI (MD)
Entity Type:Individual
Prefix:
First Name:VICHAI
Middle Name:
Last Name:LOTONGKHUM
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 1:361 STOCKHOLM ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4025
Mailing Address - Country:US
Mailing Address - Phone:718-381-2121
Mailing Address - Fax:718-497-0740
Practice Address - Street 1:361 STOCKHOLM ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4025
Practice Address - Country:US
Practice Address - Phone:718-381-2121
Practice Address - Fax:718-497-0740
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127806207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP418016OtherOXFORD
NY00237334Medicaid
NY297161Medicare ID - Type Unspecified
NYB12466Medicare UPIN