Provider Demographics
NPI:1588627293
Name:KASEMSRI, THIVAKORN (MD)
Entity Type:Individual
Prefix:
First Name:THIVAKORN
Middle Name:
Last Name:KASEMSRI
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 1:5219 CITY BANK PKWY STE 35
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-3545
Mailing Address - Country:US
Mailing Address - Phone:806-761-0333
Mailing Address - Fax:806-782-0097
Practice Address - Street 1:602 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-3364
Practice Address - Country:US
Practice Address - Phone:806-775-8813
Practice Address - Fax:806-775-9182
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0841208000000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144993601Medicaid
G66714Medicare UPIN
TX8603M9Medicare ID - Type Unspecified