Provider Demographics
NPI:1417940883
Name:THIRASILPA, PRAMUAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAMUAN
Middle Name:
Last Name:THIRASILPA
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 1:948 EBERSOLE BLVD
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-1413
Mailing Address - Country:US
Mailing Address - Phone:419-435-8159
Mailing Address - Fax:419-435-8150
Practice Address - Street 1:948 EBERSOLE BLVD
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-1413
Practice Address - Country:US
Practice Address - Phone:419-435-8159
Practice Address - Fax:419-435-8150
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35034307207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
02613OtherPARAMOUNT
4239722OtherAETNA
OH010048936OtherRR MEDICARE
OH2221113OtherCIGNA
OH0000023395703OtherUNITED HEALTH CARE
OH0195435Medicaid
OH000000130594OtherANTHEM BCBS
4239722OtherAETNA
OH$$$$$$$$$001OtherMMO
4239722OtherAETNA
TH0605741Medicare ID - Type Unspecified