Provider Demographics
NPI:1043237076
Name:THAVARADHARA, PATHOM (MD)
Entity Type:Individual
Prefix:
First Name:PATHOM
Middle Name:
Last Name:THAVARADHARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W 30TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PAMPA
Mailing Address - State:TX
Mailing Address - Zip Code:79065-2814
Mailing Address - Country:US
Mailing Address - Phone:806-669-2900
Mailing Address - Fax:806-669-2301
Practice Address - Street 1:100 W 30TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:PAMPA
Practice Address - State:TX
Practice Address - Zip Code:79065-2814
Practice Address - Country:US
Practice Address - Phone:806-669-2900
Practice Address - Fax:806-669-2301
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8581207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8M7360OtherBLUE CROSS/BLUE SHIELD
P00209318OtherRAILROAD MEDICARE, PALMETTO GBA
TX167273501Medicaid
TXD49465Medicare UPIN
TX8B9799Medicare PIN