Provider Demographics
NPI:1659507143
Name:VICHA JANVIRIYA MDPC
Entity Type:Organization
Organization Name:VICHA JANVIRIYA MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JANVIRIYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-368-1600
Mailing Address - Street 1:28750 SAN CARLOS ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2373
Mailing Address - Country:US
Mailing Address - Phone:313-368-1600
Mailing Address - Fax:
Practice Address - Street 1:28750 SAN CARLOS ST
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2373
Practice Address - Country:US
Practice Address - Phone:313-368-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032436207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102091256Medicaid
MI102091256Medicaid