Provider Demographics
NPI:1013901552
Name:PRIROMPRINTR, VISITH (MD)
Entity Type:Individual
Prefix:
First Name:VISITH
Middle Name:
Last Name:PRIROMPRINTR
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 1:11441 HEACOCK ST
Mailing Address - Street 2:SUITE B1
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7907
Mailing Address - Country:US
Mailing Address - Phone:951-924-1906
Mailing Address - Fax:951-486-9196
Practice Address - Street 1:11441 HEACOCK ST
Practice Address - Street 2:SUITE B1
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-7907
Practice Address - Country:US
Practice Address - Phone:951-924-1906
Practice Address - Fax:951-486-9196
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40164207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA401640Medicaid
CAOOA401640Medicare ID - Type Unspecified
A29063Medicare UPIN