Provider Demographics
NPI:1528199866
Name:VONGTHAVARAVAT, VERAPAN (MD)
Entity Type:Individual
Prefix:
First Name:VERAPAN
Middle Name:
Last Name:VONGTHAVARAVAT
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 1:4811 GAILLARDIA PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-1874
Mailing Address - Country:US
Mailing Address - Phone:405-751-4199
Mailing Address - Fax:405-607-1848
Practice Address - Street 1:4811 GAILLARDIA PKWY STE 200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-1874
Practice Address - Country:US
Practice Address - Phone:405-751-4199
Practice Address - Fax:405-607-1848
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21093207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7605381OtherAETNA
WA8428732Medicaid
WA1017VAOtherREGENCE BLUE SHIELD
WA1017VAOtherASURIS NW
OR213563Medicaid
WA5166925OtherPPNI
WA5741926OtherFIRST HEALTH CCN COVENTRY
WA9395857OtherPCHS MULTIPLAN
WA1017VAOtherASURIS NW
WA5741926OtherFIRST HEALTH CCN COVENTRY
WAP00290066Medicare ID - Type UnspecifiedRAILROAD MEDICARE