Provider Demographics
NPI:1972709152
Name:DEJO VIPRAKASIT, MD PC
Entity type:Organization
Organization Name:DEJO VIPRAKASIT, MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-476-1135
Mailing Address - Street 1:1995 HIGHWAY 51 SOUTH
Mailing Address - Street 2:SUITE 104
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-3635
Mailing Address - Country:US
Mailing Address - Phone:901-476-1135
Mailing Address - Fax:901-476-1136
Practice Address - Street 1:1995 HIGHWAY 51 SOUTH
Practice Address - Street 2:SUITE 104
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-3635
Practice Address - Country:US
Practice Address - Phone:901-476-1135
Practice Address - Fax:901-476-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3383546Medicare ID - Type Unspecified
TNB03093Medicare UPIN
TN3165085Medicare PIN