Provider Demographics
NPI:1861459109
Name:CHATSUTHIPHAN, VISIT (MD)
Entity Type:Individual
Prefix:
First Name:VISIT
Middle Name:
Last Name:CHATSUTHIPHAN
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 1:1809 W REDLANDS BLVD
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8054
Mailing Address - Country:US
Mailing Address - Phone:909-335-3026
Mailing Address - Fax:909-335-3167
Practice Address - Street 1:23110 ATLANTIC CIR STE F
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5920
Practice Address - Country:US
Practice Address - Phone:951-243-6455
Practice Address - Fax:951-243-0207
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA323382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A26771Medicare UPIN
CAOOA32338Medicare ID - Type Unspecified
OOA323380Medicare PIN