Provider Demographics
NPI:1073508438
Name:THEPMANKORN, PIDOK (MD)
Entity Type:Individual
Prefix:DR
First Name:PIDOK
Middle Name:
Last Name:THEPMANKORN
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 1:66 W GILBERT STREET
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4918
Mailing Address - Country:US
Mailing Address - Phone:732-212-0060
Mailing Address - Fax:
Practice Address - Street 1:495 N 13TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1317
Practice Address - Country:US
Practice Address - Phone:973-268-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03010300207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2378205Medicaid
NJ2378205Medicaid
NJ457111UWYMedicare PIN
NJ457111Medicare ID - Type Unspecified
NJ183757UWXMedicare PIN
NJC55881Medicare UPIN
NJ457111UXLMedicare PIN