Provider Demographics
NPI:1508120577
Name:MALAVONG, VIENGXAY THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:VIENGXAY
Middle Name:THOMAS
Last Name:MALAVONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 GATEWAY DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-6869
Mailing Address - Country:US
Mailing Address - Phone:334-203-1723
Mailing Address - Fax:
Practice Address - Street 1:2202 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-6869
Practice Address - Country:US
Practice Address - Phone:334-203-1723
Practice Address - Fax:888-583-3618
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALL3637R390200000X
ALDO1492207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program