Provider Demographics
NPI:1508219940
Name:NORGAIS, KONCHOK (MD)
Entity Type:Individual
Prefix:
First Name:KONCHOK
Middle Name:
Last Name:NORGAIS
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 1:788 SERVICE RD RM B301
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7013
Mailing Address - Country:US
Mailing Address - Phone:517-353-5100
Mailing Address - Fax:517-432-2759
Practice Address - Street 1:804 SERVICE RD RM A225
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7015
Practice Address - Country:US
Practice Address - Phone:517-353-4941
Practice Address - Fax:517-432-3145
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301110637207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine