Provider Demographics
NPI:1356385918
Name:KHAMVONGSA, PETER ALOYSIUS (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:ALOYSIUS
Last Name:KHAMVONGSA
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 1:10060 SW 57TH CT
Mailing Address - Street 2:THE ARBORETUM ESTATES
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-2000
Mailing Address - Country:US
Mailing Address - Phone:305-662-5058
Mailing Address - Fax:
Practice Address - Street 1:8950 N KENDALL DR
Practice Address - Street 2:MEDICAL ARTS BUILDING SUITE 302
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2144
Practice Address - Country:US
Practice Address - Phone:305-595-4070
Practice Address - Fax:305-595-3526
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88695207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
37744Medicare ID - Type Unspecified
G99727Medicare UPIN