Provider Demographics
NPI:1801953492
Name:JAYASVASTI, VACHAREEPORN TAHKI (DO)
Entity type:Individual
Prefix:
First Name:VACHAREEPORN
Middle Name:TAHKI
Last Name:JAYASVASTI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:V
Other - Middle Name:TAHKI
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:3100 CROSS CREEK PKWY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-2774
Mailing Address - Country:US
Mailing Address - Phone:248-377-0600
Mailing Address - Fax:248-377-0606
Practice Address - Street 1:3100 CROSS CREEK PKWY
Practice Address - Street 2:SUITE 220
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2774
Practice Address - Country:US
Practice Address - Phone:248-377-0600
Practice Address - Fax:248-377-0606
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014399207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4976294Medicaid
MIH72426Medicare PIN
A66000088Medicare PIN