Provider Demographics
NPI:1043490949
Name:IAMPHONGSAI, SEREE (MD)
Entity type:Individual
Prefix:MR
First Name:SEREE
Middle Name:
Last Name:IAMPHONGSAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12000 FAIRHILL RD APT 408
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-1055
Mailing Address - Country:US
Mailing Address - Phone:216-721-4129
Mailing Address - Fax:
Practice Address - Street 1:11000 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1714
Practice Address - Country:US
Practice Address - Phone:216-844-4780
Practice Address - Fax:216-844-8667
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program