Healthcare Provider Details

I. General information

NPI: 1215931555
Provider Name (Legal Business Name): VANITCHA R PINTAVORN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 TOWN PARK BLVD SUITE 1A
EVANS GA
30809-3091
US

IV. Provider business mailing address

418 TOWN PARK BLVD SUITE 1A
EVANS GA
30809-3091
US

V. Phone/Fax

Practice location:
  • Phone: 706-650-1662
  • Fax: 706-854-2131
Mailing address:
  • Phone: 706-650-1662
  • Fax: 706-854-2131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number048291
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: