Basic Information
| Provider Information | |||||||||
| NPI: | 1740370188 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCARTHY | ||||||||
| FirstName: | VONGPHETH | ||||||||
| MiddleName: | LUANGPHAXAY | ||||||||
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| OtherLastName: | LUANGPHAXAY | ||||||||
| OtherFirstName: | VONGPHETH | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 173862 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802173862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 S POTOMAC ST | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800125411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2006 | ||||||||
| LastUpdateDate: | 04/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD00046618 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207PP0204X | 48651 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8459422 | 05 | WA | MEDICAID | 95002782 | 05 | CO | MEDICAID | P00835980 | 01 | CO | RAILROAD PIN | OTHER |