Provider Demographics
NPI:1851360796
Name:LIENGSWANGWONG, VIC (MD)
Entity Type:Individual
Prefix:
First Name:VIC
Middle Name:
Last Name:LIENGSWANGWONG
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 1:1701 VETERANS DR STE 190
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-4928
Mailing Address - Country:US
Mailing Address - Phone:256-629-4800
Mailing Address - Fax:256-629-4899
Practice Address - Street 1:1751 VETERANS DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-4929
Practice Address - Country:US
Practice Address - Phone:256-629-4800
Practice Address - Fax:256-629-4899
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN348832085R0001X
WI63950-202085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL275404Medicaid
WI34075000Medicaid
MN1296554OtherAMERICA'S PPO
MN151702OtherUCARE MN
MNHP32879OtherHEALTHPARTNERS
MN69B76LIOtherBLUE CROSS BLUE SHIELD MN
MN1027665OtherPREFERRED ONE
MN095514100Medicaid
MN2400058OtherMEDICA
MN69B76LIOtherBLUE CROSS BLUE SHIELD MN
MN1296554OtherAMERICA'S PPO