Provider Demographics
NPI:1790011930
Name:SRISUKSATE, VICHEN (DAOM)
Entity Type:Individual
Prefix:DR
First Name:VICHEN
Middle Name:
Last Name:SRISUKSATE
Suffix:
Gender:M
Credentials:DAOM
Other - Prefix:DR
Other - First Name:DARBY
Other - Middle Name:
Other - Last Name:SRISUK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DAOM
Mailing Address - Street 1:5 JAMES CT
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2323
Mailing Address - Country:US
Mailing Address - Phone:925-286-3733
Mailing Address - Fax:
Practice Address - Street 1:1590 EL CAMINO REAL, STE G
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-5377
Practice Address - Country:US
Practice Address - Phone:925-286-3733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11157171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist