Provider Demographics
NPI:1124172622
Name:CHEANVECHAI, VASANA (MD,)
Entity type:Individual
Prefix:
First Name:VASANA
Middle Name:
Last Name:CHEANVECHAI
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 1:4800 NE 20TH TER STE 109
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4510
Mailing Address - Country:US
Mailing Address - Phone:954-338-3021
Mailing Address - Fax:954-357-1427
Practice Address - Street 1:4800 NE 20TH TER STE 109
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308
Practice Address - Country:US
Practice Address - Phone:954-338-3021
Practice Address - Fax:954-357-1427
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME702432086S0129X
NV116622086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCC1844OtherANTHEM BLUE C & BLUE S
NV100508393Medicaid
NV203717237OtherTIN
NV100508393Medicaid
NVH54607Medicare UPIN
NV101865Medicare PIN