Provider Demographics
NPI:1255372041
Name:VANITCHA R PINTAVORN
Entity type:Organization
Organization Name:VANITCHA R PINTAVORN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VANITCHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PINTAVORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-650-1662
Mailing Address - Street 1:418 TOWN PARK BLVD
Mailing Address - Street 2:STE 1A
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3090
Mailing Address - Country:US
Mailing Address - Phone:706-650-1662
Mailing Address - Fax:706-854-2131
Practice Address - Street 1:418 TOWN PARK BLVD
Practice Address - Street 2:STE 1A
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3090
Practice Address - Country:US
Practice Address - Phone:706-650-1662
Practice Address - Fax:706-854-2131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048291207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG48291Medicaid
GA52837117OtherBCBS
GA000894154DMedicaid
GA03BRBRDMedicare ID - Type Unspecified
SCG48291Medicaid