Provider Demographics
NPI:1609924984
Name:THAMMAVONG, ROULAY (MD)
Entity Type:Individual
Prefix:
First Name:ROULAY
Middle Name:
Last Name:THAMMAVONG
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 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:200 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3808
Practice Address - Country:US
Practice Address - Phone:513-424-2535
Practice Address - Fax:513-424-0363
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237174207R00000X
PAMD431273207R00000X
OH35.093551207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2799959Medicaid
OHTH4276741Medicare PIN