Provider Demographics
NPI:1649376534
Name:KONGCHALALAI, AMARIN (MD)
Entity type:Individual
Prefix:
First Name:AMARIN
Middle Name:
Last Name:KONGCHALALAI
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 1:9655 MONTE VISTA AVE
Mailing Address - Street 2:#402
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763
Mailing Address - Country:US
Mailing Address - Phone:909-626-1205
Mailing Address - Fax:909-625-1977
Practice Address - Street 1:9655 MONTE VISTA AVE
Practice Address - Street 2:#402
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763
Practice Address - Country:US
Practice Address - Phone:909-626-1205
Practice Address - Fax:909-625-1977
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67705207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A677050Medicaid
CA00A677050Medicaid
CAG71087Medicare UPIN
CA00A677050Medicare PIN