Provider Demographics
NPI:1902061716
Name:VECHVITVARAKUL, SUTTATIP (MD)
Entity Type:Individual
Prefix:
First Name:SUTTATIP
Middle Name:
Last Name:VECHVITVARAKUL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15030 7TH ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-3811
Mailing Address - Country:US
Mailing Address - Phone:760-951-0065
Mailing Address - Fax:
Practice Address - Street 1:15030 7TH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3811
Practice Address - Country:US
Practice Address - Phone:760-951-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1359202086S0129X
IL0361258292086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery