Provider Demographics
NPI:1265567242
Name:JONGLERTHAM, PORNCHAI (MD)
Entity type:Individual
Prefix:
First Name:PORNCHAI
Middle Name:
Last Name:JONGLERTHAM
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 1:815 N KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-4470
Mailing Address - Country:US
Mailing Address - Phone:402-460-5899
Mailing Address - Fax:402-460-5898
Practice Address - Street 1:815 N KANSAS AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-4470
Practice Address - Country:US
Practice Address - Phone:402-460-5899
Practice Address - Fax:402-460-5898
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15910207RH0003X
TXN0144207RH0003X
NE24180207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE00195OtherBC/BS INDIVIDUAL NUMBER
P00436187OtherRAILROAD MEDICARE PTAN
TX195586603Medicaid
TX195586601Medicaid
TX195586602Medicaid
252609OtherMIDLANDS CHOICE
TX8L1537Medicare PIN
TX8K9931Medicare PIN
252609OtherMIDLANDS CHOICE
P00436187OtherRAILROAD MEDICARE PTAN