Provider Demographics
NPI:1114031895
Name:THAMMASITBOON, SUPAT (MD)
Entity Type:Individual
Prefix:
First Name:SUPAT
Middle Name:
Last Name:THAMMASITBOON
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 1:1430 TULANE AVE
Mailing Address - Street 2:SL-9
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2632
Mailing Address - Country:US
Mailing Address - Phone:504-988-2250
Mailing Address - Fax:
Practice Address - Street 1:1430 TULANE AVE
Practice Address - Street 2:SL-9
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2632
Practice Address - Country:US
Practice Address - Phone:504-988-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13682R207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1424871Medicaid
LA4J1786677Medicare ID - Type Unspecified
LA1424871Medicaid