Healthcare Provider Details

I. General information

NPI: 1659428001
Provider Name (Legal Business Name): VIRUCH VACHIRAKORNTONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15998 QUANTICO RD STE A
APPLE VALLEY CA
92307-1302
US

IV. Provider business mailing address

15998 QUANTICO RD STE A
APPLE VALLEY CA
92307-1302
US

V. Phone/Fax

Practice location:
  • Phone: 760-242-2271
  • Fax: 760-242-4491
Mailing address:
  • Phone: 760-242-2271
  • Fax: 760-242-4491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA52656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: