Provider Demographics
NPI:1124002951
Name:VIJITBENJARONK, PRASERT (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASERT
Middle Name:
Last Name:VIJITBENJARONK
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3900 ST FRANCIS WAY STE 200
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4940
Practice Address - Country:US
Practice Address - Phone:765-775-2800
Practice Address - Fax:765-775-2831
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004009714174400000X, 207RC0000X
IN01090864A207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No174400000XOther Service ProvidersSpecialist
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO653949OtherHEALTHLINK
AR155765001Medicaid
126814OtherBCBS
P00244271OtherRAILROAD MEDICARE
MO207663907Medicaid
250766OtherHEALTHLINK
MO190900OtherBLUE CROSS BLUE CHOICE
AR155783001Medicaid
190900OtherBCBS
MOG98340Medicare UPIN
919314479Medicare PIN
MO653949OtherHEALTHLINK
250766OtherHEALTHLINK
MO919312993Medicare ID - Type Unspecified
P00244271OtherRAILROAD MEDICARE