Provider Demographics
NPI:1346378254
Name:THEPHASDIN, JIROJ (MD)
Entity Type:Individual
Prefix:DR
First Name:JIROJ
Middle Name:
Last Name:THEPHASDIN
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 1:8695 CONNECTICUT ST STE D
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6240
Mailing Address - Country:US
Mailing Address - Phone:219-769-3812
Mailing Address - Fax:219-736-5341
Practice Address - Street 1:8695 CONNECTICUT ST STE D
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6240
Practice Address - Country:US
Practice Address - Phone:219-769-3812
Practice Address - Fax:219-736-5341
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026596A207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0091108085OtherBCBS OF ILLINOIS
IN306516OtherBCBS OF INDIANA
INB28823Medicare UPIN
IN306516OtherBCBS OF INDIANA