Provider Demographics
NPI:1205279759
Name:KHOUSAKOUN, SOMPHANH TYNOI (DO)
Entity type:Individual
Prefix:DR
First Name:SOMPHANH
Middle Name:TYNOI
Last Name:KHOUSAKOUN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 GULF TO BAY BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-5315
Mailing Address - Country:US
Mailing Address - Phone:727-498-0808
Mailing Address - Fax:727-477-8303
Practice Address - Street 1:1433 GULF TO BAY BLVD STE F
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-5315
Practice Address - Country:US
Practice Address - Phone:727-498-0808
Practice Address - Fax:727-477-8303
Is Sole Proprietor?:No
Enumeration Date:2013-04-15
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS147032084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022915800Medicaid