Provider Demographics
NPI:1689366767
Name:AMALATHASAN, THEOURN (MD)
Entity Type:Individual
Prefix:MR
First Name:THEOURN
Middle Name:
Last Name:AMALATHASAN
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 1:22250 PROVIDENCE DRIVE
Mailing Address - Street 2:7PMB SUITE #703A
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4818
Mailing Address - Country:US
Mailing Address - Phone:248-849-3254
Mailing Address - Fax:248-849-5449
Practice Address - Street 1:22250 PROVIDENCE DRIVE
Practice Address - Street 2:7PMB SUITE #703A
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3254
Practice Address - Fax:248-849-5449
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2024-03-05
Deactivation Date:2023-12-28
Deactivation Code:
Reactivation Date:2024-03-05
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program