Provider Demographics
NPI:1639206154
Name:VONGSVIVUT, ARBHA (MD)
Entity Type:Individual
Prefix:
First Name:ARBHA
Middle Name:
Last Name:VONGSVIVUT
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 1:815 E 5TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002
Mailing Address - Country:US
Mailing Address - Phone:618-462-0547
Mailing Address - Fax:618-462-0570
Practice Address - Street 1:815 E 5TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002
Practice Address - Country:US
Practice Address - Phone:618-462-0547
Practice Address - Fax:618-462-0570
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C38021Medicare UPIN
IL231442Medicare ID - Type Unspecified