Basic Information
| Provider Information | |||||||||
| NPI: | 1124002951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIJITBENJARONK | ||||||||
| FirstName: | PRASERT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 293 COUNTRY BLUFF DR | ||||||||
| Address2: | |||||||||
| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656168846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173340068 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1150 STATE HIGHWAY 248 | ||||||||
| Address2: | STE. 200 | ||||||||
| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656163758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173364112 | ||||||||
| FaxNumber: | 4173357588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2004009714 | MO | N | Other Service Providers | Specialist | 207RC0000X | 2004009714 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 155783001 | 05 | AR | MEDICAID | 155765001 | 05 | AR | MEDICAID | 653949 | 01 | MO | HEALTHLINK | OTHER | 207663907 | 05 | MO | MEDICAID | 126814 | 01 | BCBS | OTHER | 190900 | 01 | BCBS | OTHER | 190900 | 01 | MO | BLUE CROSS BLUE CHOICE | OTHER | 250766 | 01 | HEALTHLINK | OTHER | P00244271 | 01 | RAILROAD MEDICARE | OTHER |