Provider Demographics
NPI:1376538132
Name:VALLEY PHYSICIANS MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:VALLEY PHYSICIANS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRASERT
Authorized Official - Middle Name:BASIL
Authorized Official - Last Name:VASSANTACHART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-282-3113
Mailing Address - Street 1:841 W VALLEY BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-3251
Mailing Address - Country:US
Mailing Address - Phone:626-282-3113
Mailing Address - Fax:626-289-9179
Practice Address - Street 1:841 W VALLEY BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-3251
Practice Address - Country:US
Practice Address - Phone:626-282-3113
Practice Address - Fax:626-289-9179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGH4008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0016470Medicaid
CAGR0016470Medicaid
CAW7955Medicare ID - Type Unspecified