Provider Demographics
NPI:1659428001
Name:VACHIRAKORNTONG, VIRUCH (MD)
Entity Type:Individual
Prefix:
First Name:VIRUCH
Middle Name:
Last Name:VACHIRAKORNTONG
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 1:15998 QUANTICO RD STE A
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1302
Mailing Address - Country:US
Mailing Address - Phone:760-242-2271
Mailing Address - Fax:760-242-4491
Practice Address - Street 1:15998 QUANTICO RD STE A
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1302
Practice Address - Country:US
Practice Address - Phone:760-242-2271
Practice Address - Fax:760-242-4491
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52656207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A526561Medicaid
CA00A526560Medicaid
CA00A526560Medicaid
CA00A526560Medicare ID - Type Unspecified