Healthcare Provider Details

I. General information

NPI: 1508065145
Provider Name (Legal Business Name): VEERAVAT TAECHARVONGPHAIROJ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E LATHAM AVE STE 205
HEMET CA
92543-4391
US

IV. Provider business mailing address

1545 W FLORIDA AVE
HEMET CA
92543-3814
US

V. Phone/Fax

Practice location:
  • Phone: 951-658-7205
  • Fax: 888-696-1501
Mailing address:
  • Phone: 951-791-1111
  • Fax: 888-856-3893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA115763
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: