Provider Demographics
NPI:1841272838
Name:PUNYANITYA, VISESPONG (MD)
Entity type:Individual
Prefix:DR
First Name:VISESPONG
Middle Name:
Last Name:PUNYANITYA
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 1:411 8TH ST NE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-4727
Mailing Address - Country:US
Mailing Address - Phone:434-296-3830
Mailing Address - Fax:434-979-6181
Practice Address - Street 1:411 8TH ST NE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-4727
Practice Address - Country:US
Practice Address - Phone:434-296-3830
Practice Address - Fax:434-979-6181
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031875207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB05746Medicare UPIN