Provider Demographics
NPI:1063504074
Name:THITARAM, SOMPHONG (MD)
Entity Type:Individual
Prefix:DR
First Name:SOMPHONG
Middle Name:
Last Name:THITARAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2550 WINDY HILL RD SE
Mailing Address - Street 2:106
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8665
Mailing Address - Country:US
Mailing Address - Phone:770-955-4314
Mailing Address - Fax:770-955-4315
Practice Address - Street 1:2550 WINDY HILL RD SE
Practice Address - Street 2:106
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8665
Practice Address - Country:US
Practice Address - Phone:770-955-4314
Practice Address - Fax:770-955-4315
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA15046208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD31000Medicare UPIN