Individual
DR. PONG LAITEERAPONG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
140 N ASHLAND AVE, CHICAGO, IL 60607
(312) 850-9411
Mailing address
140 N ASHLAND AVE, CHICAGO, IL 60607-1802
(312) 850-9411
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
O36.053201
IL
Other
Enumeration date
12/07/2012
Last updated
12/07/2012
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