Healthcare Provider Details

I. General information

NPI: 1992202899
Provider Name (Legal Business Name): ATHIP VATANAPRADITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6490 MOUNT MORIAH ROAD EXT STE 200
MEMPHIS TN
38115-3841
US

IV. Provider business mailing address

6490 MOUNT MORIAH ROAD EXT STE 200
MEMPHIS TN
38115-3841
US

V. Phone/Fax

Practice location:
  • Phone: 901-565-0244
  • Fax: 901-565-0616
Mailing address:
  • Phone: 901-565-0244
  • Fax: 901-565-0616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number72633
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: