Provider Demographics
NPI:1477619278
Name:HOMPLUEM, URAIWAN TANA (MD)
Entity Type:Individual
Prefix:DR
First Name:URAIWAN
Middle Name:TANA
Last Name:HOMPLUEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:URAIWAN
Other - Middle Name:TANA
Other - Last Name:TANANUNKUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 TERMINAL DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2268
Mailing Address - Country:US
Mailing Address - Phone:618-259-1419
Mailing Address - Fax:618-259-1502
Practice Address - Street 1:2 TERMINAL DR
Practice Address - Street 2:SUITE 8
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2268
Practice Address - Country:US
Practice Address - Phone:618-259-1419
Practice Address - Fax:618-259-1502
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067508208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067508Medicaid
E97993Medicare UPIN