Provider Demographics
NPI:1720145386
Name:SANGCHANTR, WANCHAI (MD)
Entity Type:Individual
Prefix:DR
First Name:WANCHAI
Middle Name:
Last Name:SANGCHANTR
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 1:4207 RUTGERS LN
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2913
Mailing Address - Country:US
Mailing Address - Phone:773-348-7305
Mailing Address - Fax:773-665-3728
Practice Address - Street 1:2900 N LAKE SHORE DR
Practice Address - Street 2:10TH FLOOR - GI LAB
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5640
Practice Address - Country:US
Practice Address - Phone:773-665-3084
Practice Address - Fax:773-665-3728
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILNA292929Medicaid
ILC38643Medicare UPIN
IL238650Medicare ID - Type Unspecified