Provider Demographics
NPI:1437151669
Name:THIENPRASIT, PHUDHIPHORN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:PHUDHIPHORN
Middle Name:
Last Name:THIENPRASIT
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 BEAM AVE
Mailing Address - Street 2:STE 215
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1172
Mailing Address - Country:US
Mailing Address - Phone:651-748-1461
Mailing Address - Fax:651-777-1191
Practice Address - Street 1:1675 BEAM AVE
Practice Address - Street 2:STE 215
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1172
Practice Address - Country:US
Practice Address - Phone:651-748-1461
Practice Address - Fax:651-777-1191
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21230207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA95754Medicare UPIN