MEDICARE: PRAVIR R VATSA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A95811	CA
2	208M00000X	Hospitalist Physician	A95811	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00A958110	OTHER	CA	BLUE SHIELD OF CA

General Provider Information

NPI Number	:	1003912239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRAVIR R VATSA MD

Provider Business Mailing Address
First Line	:	1023 NIPOMO ST # 110
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-3882
Country	:	US
Telephone Number	:	805-439-2998
Fax Number	:	805-439-2997

Provider Business Practice Location Address
First Line	:	1023 NIPOMO ST # 110
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-3882
Country	:	US
Telephone Number	:	805-439-2998
Fax Number	:	805-439-2997

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	08/17/2015

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