Basic Information
| Provider Information | |||||||||
| NPI: | 1750814232 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NHONTHACHIT | ||||||||
| FirstName: | PHETSAMONG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11511 SHADOW CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775847298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134420000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4755 ALDINE MAIL ROUTE RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770395934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819857600 | ||||||||
| FaxNumber: | 2819857620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2017 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 47182 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | S8351 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.