Basic Information
| Provider Information | |||||||||
| NPI: | 1285681056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUVERNAY | ||||||||
| FirstName: | VIRGIL | ||||||||
| MiddleName: | HILARN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD, FACP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5040 | ||||||||
| Address2: | |||||||||
| City: | OROVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959660040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185285268 | ||||||||
| FaxNumber: | 9187700058 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 ORO DAM BLVD E | ||||||||
| Address2: | |||||||||
| City: | OROVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959666052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307122171 | ||||||||
| FaxNumber: | 5307122149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01063909A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | A45858 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000549587 | 01 | IN | ANTHEM PIN | OTHER | 250470 | 01 | IN | MEDICARE GROUP | OTHER | 200870160 | 05 | IN | MEDICAID | 200859330C | 01 | IN | MEDICAID GROUP | OTHER |