Provider Demographics
NPI:1295821353
Name:THRUPKAEW, SOONTORN (MD)
Entity Type:Individual
Prefix:DR
First Name:SOONTORN
Middle Name:
Last Name:THRUPKAEW
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 1:2 TERMINAL DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2268
Mailing Address - Country:US
Mailing Address - Phone:618-258-0485
Mailing Address - Fax:618-258-0489
Practice Address - Street 1:2 TERMINAL DR
Practice Address - Street 2:SUITE 8
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2268
Practice Address - Country:US
Practice Address - Phone:618-258-0485
Practice Address - Fax:618-258-0489
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048881207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048881Medicaid
IL036048881Medicaid
ILL95757Medicare ID - Type Unspecified