Provider Demographics
NPI:1740589910
Name:BUNYAVANICH, SOMMAI (MD)
Entity Type:Individual
Prefix:DR
First Name:SOMMAI
Middle Name:
Last Name:BUNYAVANICH
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 1:6200 BEACH CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1409
Mailing Address - Country:US
Mailing Address - Phone:718-945-7150
Mailing Address - Fax:718-318-4809
Practice Address - Street 1:6200 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1409
Practice Address - Country:US
Practice Address - Phone:718-945-7150
Practice Address - Fax:718-318-4809
Is Sole Proprietor?:No
Enumeration Date:2011-03-27
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117347-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00527977Medicaid
NY00527977Medicaid