Provider Demographics
NPI:1225055882
Name:SUDHIPONG, VIMORNWAN (MD)
Entity Type:Individual
Prefix:
First Name:VIMORNWAN
Middle Name:
Last Name:SUDHIPONG
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:PO BOX 409036
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-9036
Mailing Address - Country:US
Mailing Address - Phone:352-369-0948
Mailing Address - Fax:904-346-0113
Practice Address - Street 1:6500 W NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4309
Practice Address - Country:US
Practice Address - Phone:352-333-4900
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060722207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA882456662AMedicaid
FL26465OtherBCBS
FL930098050OtherRAILROAD MEDICARE
FL377247100Medicaid
FLF96106Medicare UPIN
GA882456662AMedicaid