Provider Demographics
NPI:1467439828
Name:SRISUWANANUKORN, SOMPOP (MD)
Entity Type:Individual
Prefix:
First Name:SOMPOP
Middle Name:
Last Name:SRISUWANANUKORN
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 1:9201 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2807
Mailing Address - Country:US
Mailing Address - Phone:219-836-2022
Mailing Address - Fax:219-836-1072
Practice Address - Street 1:2075 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:IN
Practice Address - Zip Code:46394-1948
Practice Address - Country:US
Practice Address - Phone:219-659-7000
Practice Address - Fax:219-659-9018
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030518207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100188330Medicaid
IN100188330Medicaid
E05801Medicare UPIN