Provider Demographics
NPI:1851824379
Name:VONGVIPHUT, KSENIA MARY (DO)
Entity Type:Individual
Prefix:MRS
First Name:KSENIA
Middle Name:MARY
Last Name:VONGVIPHUT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KSENIA
Other - Middle Name:
Other - Last Name:ROGALO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2225 E. EVESHAM RD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043
Mailing Address - Country:US
Mailing Address - Phone:484-476-2000
Mailing Address - Fax:
Practice Address - Street 1:2225 E EVESHAM RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-1557
Practice Address - Country:US
Practice Address - Phone:856-795-4330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program