Basic Information
| Provider Information | |||||||||
| NPI: | 1649376534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONGCHALALAI | ||||||||
| FirstName: | AMARIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9655 MONTE VISTA AVE | ||||||||
| Address2: | #402 | ||||||||
| City: | MONTCLAIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096261205 | ||||||||
| FaxNumber: | 9096251977 | ||||||||
| Practice Location | |||||||||
| Address1: | 9655 MONTE VISTA AVE | ||||||||
| Address2: | #402 | ||||||||
| City: | MONTCLAIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096261205 | ||||||||
| FaxNumber: | 9096251977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 04/22/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | A67705 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 00A677050 | 05 | CA | MEDICAID |