Provider Demographics
NPI:1720041429
Name:CHUNGCHANSAT, PORNTIP (MD)
Entity Type:Individual
Prefix:
First Name:PORNTIP
Middle Name:
Last Name:CHUNGCHANSAT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 22ND PLACE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410
Mailing Address - Country:US
Mailing Address - Phone:806-725-7800
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:416 FRANKFORD
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416
Practice Address - Country:US
Practice Address - Phone:806-725-5410
Practice Address - Fax:806-792-7157
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138095812Medicaid
TX8578M4Medicare PIN
TX138095812Medicaid