Provider Demographics
NPI:1891748463
Name:VUTHIGANON, CHATCHAVAL (MD)
Entity Type:Individual
Prefix:MR
First Name:CHATCHAVAL
Middle Name:
Last Name:VUTHIGANON
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:PO BOX 1266
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-2621
Mailing Address - Country:US
Mailing Address - Phone:843-726-4527
Mailing Address - Fax:
Practice Address - Street 1:1506 GRAYS HIGHWAY
Practice Address - Street 2:SUITE C
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936
Practice Address - Country:US
Practice Address - Phone:843-726-4527
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11376208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC113763Medicaid
SC113763Medicaid