Provider Demographics
NPI:1982973970
Name:KONGTAHWORN, CHAMNAHN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAMNAHN
Middle Name:
Last Name:KONGTAHWORN
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 1:12950 WOODLANDS PKWY
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8748
Mailing Address - Country:US
Mailing Address - Phone:515-225-2369
Mailing Address - Fax:
Practice Address - Street 1:12950 WOODLANDS PKWY
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8748
Practice Address - Country:US
Practice Address - Phone:515-225-2369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20052208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA20052OtherMEDICAL LICENSE