Provider Demographics
NPI:1568496040
Name:SOMBUN, TIRDKIAT (MD)
Entity Type:Individual
Prefix:DR
First Name:TIRDKIAT
Middle Name:
Last Name:SOMBUN
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 1:330 N WABASH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-662-8533
Mailing Address - Fax:765-668-4167
Practice Address - Street 1:330 N WABASH AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2600
Practice Address - Country:US
Practice Address - Phone:765-662-8533
Practice Address - Fax:765-668-4167
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036206A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC43701Medicare UPIN
IN861500Medicare ID - Type UnspecifiedMEDICARE