Individual
DR. PENPORN VONGSVIVUT RECK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
345 COLLEGE ST SE STE C, LACEY, WA 98503-1014
(360) 456-3200
(360) 456-3894
Mailing address
345 COLLEGE ST SE, SUITE C, LACEY, WA 98503-1014
(360) 456-3200
(360) 456-3894
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
MD00049407
WA
207WX0107X
Retina Specialist (Ophthalmology) Physician
MD00049407
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8511552
—
WA
Enumeration date
07/25/2006
Last updated
04/10/2025
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