Provider Demographics
NPI:1558489195
Name:OPHAS VONGXAIBURANA, MD,PC
Entity Type:Organization
Organization Name:OPHAS VONGXAIBURANA, MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OPHAS
Authorized Official - Middle Name:
Authorized Official - Last Name:VONGXAIBURANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-725-9794
Mailing Address - Street 1:201 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:RANSON
Mailing Address - State:WV
Mailing Address - Zip Code:25438-1613
Mailing Address - Country:US
Mailing Address - Phone:304-725-9794
Mailing Address - Fax:304-728-4794
Practice Address - Street 1:201 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438-1613
Practice Address - Country:US
Practice Address - Phone:304-725-9794
Practice Address - Fax:304-728-4794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10256208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVE05096Medicare UPIN
WV0408881Medicare ID - Type Unspecified