Provider Demographics
NPI:1851466650
Name:VONGSAVATH, KEN THOMAS (PAC)
Entity Type:Individual
Prefix:MR
First Name:KEN
Middle Name:THOMAS
Last Name:VONGSAVATH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 E STOCKTON
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:TX
Mailing Address - Zip Code:79830
Mailing Address - Country:US
Mailing Address - Phone:432-837-9188
Mailing Address - Fax:432-837-9188
Practice Address - Street 1:2071 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FT STOCKTON
Practice Address - State:TX
Practice Address - Zip Code:79735
Practice Address - Country:US
Practice Address - Phone:432-336-0700
Practice Address - Fax:432-336-0704
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00172207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
S06756Medicare UPIN