Provider Demographics
NPI:1982696969
Name:KANJANAPONE, VALLOP (MD)
Entity Type:Individual
Prefix:
First Name:VALLOP
Middle Name:
Last Name:KANJANAPONE
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 1:1665 S IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-4247
Mailing Address - Country:US
Mailing Address - Phone:760-352-7216
Mailing Address - Fax:760-352-1028
Practice Address - Street 1:1665 S IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4247
Practice Address - Country:US
Practice Address - Phone:760-352-7216
Practice Address - Fax:760-352-1028
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA33464OtherMEDICAL LICENSE