Provider Demographics
NPI:1518499805
Name:PONGVITAYAPANU, RICHARD RITT (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:RITT
Last Name:PONGVITAYAPANU
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 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-2710
Mailing Address - Fax:631-444-7865
Practice Address - Street 1:600 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934-2207
Practice Address - Country:US
Practice Address - Phone:631-444-5437
Practice Address - Fax:631-444-7865
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304145208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics