Provider Demographics
NPI:1548606924
Name:VIJITAKULA, SORAPAT (MD)
Entity Type:Individual
Prefix:
First Name:SORAPAT
Middle Name:
Last Name:VIJITAKULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PAT
Other - Middle Name:
Other - Last Name:VIJITAKULA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11100 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-3610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.128916207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program