Provider Demographics
NPI:1992754899
Name:VIRUCH VACHIRAKORNTONG MD INC
Entity type:Organization
Organization Name:VIRUCH VACHIRAKORNTONG MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIRUCH
Authorized Official - Middle Name:
Authorized Official - Last Name:VACHIRAKORNTONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-242-2271
Mailing Address - Street 1:15998 QUANTICO RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1302
Mailing Address - Country:US
Mailing Address - Phone:760-242-2271
Mailing Address - Fax:760-242-4491
Practice Address - Street 1:15998 QUANTICO RD
Practice Address - Street 2:SUITE A
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1302
Practice Address - Country:US
Practice Address - Phone:760-242-2271
Practice Address - Fax:760-242-4491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB51470FMedicaid
CA00A526560Medicaid
CA00A526561Medicaid
CA00A526560Medicare PIN
CALAB51470FMedicaid
G09313Medicare UPIN
CA00A526561Medicaid
CACE29OZMedicare PIN