Provider Demographics
NPI:1689687238
Name:THAMBAN, IMMANUEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:IMMANUEL
Middle Name:S
Last Name:THAMBAN
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 1:11004 WILLOW BEND DR
Mailing Address - Street 2:
Mailing Address - City:WOODWAY
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4800 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-1329
Practice Address - Country:US
Practice Address - Phone:254-297-3735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism