Provider Demographics
NPI:1942250659
Name:CHANTORNSAENG, KONGSAK (MD)
Entity Type:Individual
Prefix:
First Name:KONGSAK
Middle Name:
Last Name:CHANTORNSAENG
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 1:403 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-3409
Mailing Address - Country:US
Mailing Address - Phone:185-074-7559
Mailing Address - Fax:850-279-6771
Practice Address - Street 1:403 E 11TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3409
Practice Address - Country:US
Practice Address - Phone:185-074-7559
Practice Address - Fax:850-279-6771
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86600207P00000X, 207RE0101X, 207RG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266360100Medicaid
FL57676BMedicare Oscar/Certification
FL57676XMedicare PIN
FLH81034Medicare UPIN