Provider Demographics
NPI:1992202899
Name:VATANAPRADITH, ATHIP (MD)
Entity type:Individual
Prefix:
First Name:ATHIP
Middle Name:
Last Name:VATANAPRADITH
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 1:6490 MOUNT MORIAH ROAD EXT STE 200
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-3841
Mailing Address - Country:US
Mailing Address - Phone:901-565-0244
Mailing Address - Fax:901-565-0616
Practice Address - Street 1:6490 MOUNT MORIAH ROAD EXT STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-3841
Practice Address - Country:US
Practice Address - Phone:901-565-0244
Practice Address - Fax:901-565-0616
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN72633207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program