Provider Demographics
NPI:1255312096
Name:VIPRAKASIT, DEJO (MD)
Entity Type:Individual
Prefix:MR
First Name:DEJO
Middle Name:
Last Name:VIPRAKASIT
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 388
Mailing Address - Street 2:1995 HWY 51 SOUTH SUITE 104
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019
Mailing Address - Country:US
Mailing Address - Phone:901-476-1135
Mailing Address - Fax:901-476-1136
Practice Address - Street 1:1995 HWY 51 SOUTH
Practice Address - Street 2:SUITE 104
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019
Practice Address - Country:US
Practice Address - Phone:901-476-1135
Practice Address - Fax:901-476-1136
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD11008208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3383546Medicaid
4031846OtherAETNA
TN2007928OtherBLUE CROSS
TN3383546Medicare ID - Type Unspecified
TN3383546Medicaid