Provider Demographics
NPI:1730315656
Name:PHAVIXAY, LAEMTHONG X (DPM)
Entity Type:Individual
Prefix:DR
First Name:LAEMTHONG
Middle Name:X
Last Name:PHAVIXAY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 W 3RD ST
Mailing Address - Street 2:PODIATRY 112P
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45428-9000
Mailing Address - Country:US
Mailing Address - Phone:937-268-6511
Mailing Address - Fax:937-267-5395
Practice Address - Street 1:4100 W 3RD ST
Practice Address - Street 2:PODIATRY 112P
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428-9000
Practice Address - Country:US
Practice Address - Phone:937-268-6511
Practice Address - Fax:937-267-5395
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program