Provider Demographics
NPI:1669726832
Name:DISTHA-BANCHONG, SINEE (MD)
Entity type:Individual
Prefix:DR
First Name:SINEE
Middle Name:
Last Name:DISTHA-BANCHONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SINEE
Other - Middle Name:
Other - Last Name:DISTHABANCHONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1402 S GRAND BLVD
Mailing Address - Street 2:DIVISION OF NEPHROLOGY (9-FDT)
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1004
Mailing Address - Country:US
Mailing Address - Phone:314-577-8765
Mailing Address - Fax:
Practice Address - Street 1:1402 S GRAND BLVD
Practice Address - Street 2:DIVISION OF NEPHROLOGY (9-FDT)
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1004
Practice Address - Country:US
Practice Address - Phone:314-577-8765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012037985207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine