Provider Demographics
NPI:1215931555
Name:PINTAVORN, VANITCHA R (MD)
Entity type:Individual
Prefix:
First Name:VANITCHA
Middle Name:R
Last Name:PINTAVORN
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 1:418 TOWN PARK BLVD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3091
Mailing Address - Country:US
Mailing Address - Phone:706-650-1662
Mailing Address - Fax:706-854-2131
Practice Address - Street 1:418 TOWN PARK BLVD
Practice Address - Street 2:SUITE 1A
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3091
Practice Address - Country:US
Practice Address - Phone:706-650-1662
Practice Address - Fax:706-854-2131
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048291207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000894154DMedicaid
SCG48291Medicaid
GAH33363Medicare UPIN
GA03BDBRDMedicare ID - Type Unspecified