Provider Demographics
NPI:1932111770
Name:KOSOLCHAROEN, BUNCHONG (MD)
Entity Type:Individual
Prefix:
First Name:BUNCHONG
Middle Name:
Last Name:KOSOLCHAROEN
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:PO BOX 1769
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1769
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5196 HILL RD E STE 203
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6362
Practice Address - Country:US
Practice Address - Phone:707-263-6866
Practice Address - Fax:707-263-0376
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39985207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A399850Medicaid
CA00A399850Medicare ID - Type Unspecified
CAA 29012Medicare UPIN