Basic Information
| Provider Information | |||||||||
| NPI: | 1720022965 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | VIRAVATHANA | ||||||||
| FirstName: | THAVINSAKDI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 890 W STETSON AVE STE B | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925437311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515376002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 890 W STETSON AVE STE B | ||||||||
| Address2: | APEX RADIOLOGY MEDICAL GROUP, INC. | ||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925437311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515376002 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 02/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0203X | A34942 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A349420 | 05 | CA | MEDICAID | 00A349421 | 01 | MEDICARE PTAN | OTHER | 300127206 | 01 | CA | RAILROAD | OTHER | 00A349422 | 01 | MEDICARE PTAN | OTHER |