Basic Information
| Provider Information | |||||||||
| NPI: | 1124172622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEANVECHAI | ||||||||
| FirstName: | VASANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D., | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 NE 20TH TER STE 109 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333084510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543383021 | ||||||||
| FaxNumber: | 9543571427 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 NE 20TH TER STE 109 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543383021 | ||||||||
| FaxNumber: | 9543571427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 07/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | ME70243 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 11662 | NV | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | CC1844 | 01 | NV | ANTHEM BLUE C & BLUE S | OTHER | 100508393 | 05 | NV | MEDICAID |