Provider Demographics
NPI:1972679611
Name:THAPVONGSE, CHIN (MD)
Entity Type:Individual
Prefix:
First Name:CHIN
Middle Name:
Last Name:THAPVONGSE
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 1:28 BIRCHDALE LANE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:10050-4502
Mailing Address - Country:US
Mailing Address - Phone:516-627-2505
Mailing Address - Fax:
Practice Address - Street 1:1269 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452
Practice Address - Country:US
Practice Address - Phone:718-293-3424
Practice Address - Fax:718-293-3424
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133396208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00439978Medicaid
23A601Medicare ID - Type Unspecified
NY00439978Medicaid