Provider Demographics
NPI:1750519922
Name:KHAMVANTHONG, PHONEKEO (MD)
Entity type:Individual
Prefix:
First Name:PHONEKEO
Middle Name:
Last Name:KHAMVANTHONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3517 W OWEN K GARRIOTT RD STE 4
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-4953
Mailing Address - Country:US
Mailing Address - Phone:580-233-5553
Mailing Address - Fax:
Practice Address - Street 1:3517 W OWEN K GARRIOTT RD STE 4
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-4953
Practice Address - Country:US
Practice Address - Phone:580-233-5553
Practice Address - Fax:859-260-4350
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP911207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine