Provider Demographics
NPI:1811045198
Name:SNIDER-THAMMAVONG, ERICA G (MD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:G
Last Name:SNIDER-THAMMAVONG
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 1:5 SYCAMORE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-2300
Mailing Address - Country:US
Mailing Address - Phone:937-748-4211
Mailing Address - Fax:937-748-3566
Practice Address - Street 1:5 SYCAMORE CREEK DR
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-2300
Practice Address - Country:US
Practice Address - Phone:937-748-4211
Practice Address - Fax:937-748-3566
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237301207Q00000X
OH35.094616207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02705888Medicaid
OH0058539Medicaid
OH0058539Medicaid
NYRA9162Medicare ID - Type UnspecifiedINDIVIDUAL ID #
NY02705888Medicaid
PA118079PD9Medicare PIN