Provider Demographics
NPI:1366650236
Name:THATAYATIKOM, AKALUCK (MD)
Entity Type:Individual
Prefix:DR
First Name:AKALUCK
Middle Name:
Last Name:THATAYATIKOM
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 1:2501 N ORANGE AVE STE 586
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4603
Mailing Address - Country:US
Mailing Address - Phone:407-821-3545
Mailing Address - Fax:407-821-3546
Practice Address - Street 1:2501 N ORANGE AVE STE 586
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4603
Practice Address - Country:US
Practice Address - Phone:407-821-3545
Practice Address - Fax:407-821-3546
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060353102080P0205X
FLME1144522080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007298300Medicaid
FL007298300Medicaid