Provider Demographics
NPI:1760989636
Name:KHAMMAHAVONG, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:KHAMMAHAVONG
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 1:185 39TH ST APT D104
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15201-3235
Mailing Address - Country:US
Mailing Address - Phone:401-345-0995
Mailing Address - Fax:
Practice Address - Street 1:15107 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4542
Practice Address - Country:US
Practice Address - Phone:818-782-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD474559207P00000X
390200000X
CAA175022207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program