Provider Demographics
NPI:1356323570
Name:PATANAPHAN, VINITA (MD)
Entity Type:Individual
Prefix:
First Name:VINITA
Middle Name:
Last Name:PATANAPHAN
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:
Practice Address - Street 1:1200 BRASS MILL RD
Practice Address - Street 2:SUITE E
Practice Address - City:BELCAMP
Practice Address - State:MD
Practice Address - Zip Code:21017-1217
Practice Address - Country:US
Practice Address - Phone:410-272-9224
Practice Address - Fax:410-575-7591
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD217982085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD649911200Medicaid
MD1043770OtherCIGNA PROVIDER #
MD4421117OtherAETNA PROVIDER #
MD01189076OtherAMERIGROUP
MD34578005OtherCARE FIRST BCBS PROV. #
MD6882-0002OtherCAREFIRST BCBS- DC
MD154681300Medicaid
MD5160OtherELDER HEALTH PROVIDER #
MD5160OtherELDER HEALTH PROVIDER #
MD6882-0002OtherCAREFIRST BCBS- DC