Provider Demographics
NPI:1720022965
Name:VIRAVATHANA, THAVINSAKDI (MD)
Entity Type:Individual
Prefix:
First Name:THAVINSAKDI
Middle Name:
Last Name:VIRAVATHANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 W STETSON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-7311
Mailing Address - Country:US
Mailing Address - Phone:951-537-6002
Mailing Address - Fax:
Practice Address - Street 1:890 W STETSON AVE STE B
Practice Address - Street 2:APEX RADIOLOGY MEDICAL GROUP, INC.
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-7311
Practice Address - Country:US
Practice Address - Phone:951-537-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA349422085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A349420Medicaid
00A349421OtherMEDICARE PTAN
CA300127206OtherRAILROAD
00A349422OtherMEDICARE PTAN
00A349422OtherMEDICARE PTAN
00A349421OtherMEDICARE PTAN
CA00A349420Medicaid