1356323570 NPI number — VINITA PATANAPHAN MD

Table of content: (NPI 1508915489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356323570 NPI number — VINITA PATANAPHAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATANAPHAN
Provider First Name:
VINITA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356323570
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 BRASS MILL RD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
BELCAMP
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21017-1217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-272-9224
Provider Business Practice Location Address Fax Number:
410-575-7591
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  D21798 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 649911200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1043770 . This is a "CIGNA PROVIDER #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 4421117 . This is a "AETNA PROVIDER #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 01189076 . This is a "AMERIGROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 34578005 . This is a "CARE FIRST BCBS PROV. #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 6882-0002 . This is a "CAREFIRST BCBS- DC" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 154681300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5160 . This is a "ELDER HEALTH PROVIDER #" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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