Provider Demographics
NPI:1942362777
Name:TANPHAICHITR, KONGSAK (MD)
Entity type:Individual
Prefix:DR
First Name:KONGSAK
Middle Name:
Last Name:TANPHAICHITR
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11115 NEW HALLS FERRY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-7613
Mailing Address - Country:US
Mailing Address - Phone:314-839-4339
Mailing Address - Fax:314-839-0011
Practice Address - Street 1:11115 NEW HALLS FERRY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-7613
Practice Address - Country:US
Practice Address - Phone:314-839-4339
Practice Address - Fax:314-839-0011
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2012-08-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO35104207RA0201X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200861813Medicaid
MOA10919Medicare UPIN
MO200861813Medicaid