Provider Demographics
NPI:1548242241
Name:VIPRAKASIT, SUTTIWARA (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUTTIWARA
Middle Name:
Last Name:VIPRAKASIT
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 761
Mailing Address - Street 2:
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:BAPTIST MEMORIAL HOSPITAL TIPTON
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019
Practice Address - Country:US
Practice Address - Phone:901-476-2621
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD11009207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3384839Medicaid
B03101Medicare UPIN
3384839Medicare ID - Type Unspecified