Provider Demographics
NPI:1538111356
Name:PONGDEE, THANAI (MD)
Entity Type:Individual
Prefix:
First Name:THANAI
Middle Name:
Last Name:PONGDEE
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 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6579207K00000X, 207RA0201X, 2080P0201X
FLME107649207K00000X
MN44060207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002639900Medicaid
FL002639900Medicaid
TX8L5251Medicare PIN