Provider Demographics
NPI:1689765042
Name:VONGXAIBURANA, OPHAS (MD)
Entity Type:Individual
Prefix:DR
First Name:OPHAS
Middle Name:
Last Name:VONGXAIBURANA
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 1:201 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10256208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0408881Medicare ID - Type Unspecified
E05096Medicare UPIN