Provider Demographics
NPI:1053413179
Name:VONGVISES, MANOSH (MD)
Entity type:Individual
Prefix:
First Name:MANOSH
Middle Name:
Last Name:VONGVISES
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 1:419 TOWN MOUNTAIN RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-1631
Mailing Address - Country:US
Mailing Address - Phone:606-432-3277
Mailing Address - Fax:606-432-6771
Practice Address - Street 1:419 TOWN MOUNTAIN RD
Practice Address - Street 2:SUITE 104
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1631
Practice Address - Country:US
Practice Address - Phone:606-432-3277
Practice Address - Fax:606-432-6771
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20681207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64206816Medicaid
KY1547601Medicare ID - Type Unspecified
KYC74243Medicare UPIN