Provider Demographics
NPI:1003912239
Name:VATSA, PRAVIR R (MD)
Entity Type:Individual
Prefix:
First Name:PRAVIR
Middle Name:R
Last Name:VATSA
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 1:1023 NIPOMO ST # 110
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3882
Mailing Address - Country:US
Mailing Address - Phone:805-439-2998
Mailing Address - Fax:805-439-2997
Practice Address - Street 1:1023 NIPOMO ST # 110
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3882
Practice Address - Country:US
Practice Address - Phone:805-439-2998
Practice Address - Fax:805-439-2997
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95811207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A958110Medicaid
CA00A958110OtherBLUE SHIELD OF CA
CA00A958110Medicaid
I67386Medicare UPIN