Provider Demographics
NPI:1710221361
Name:THOMAS RODSUWAN M D PMC
Entity Type:Organization
Organization Name:THOMAS RODSUWAN M D PMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:RODSUWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-429-4930
Mailing Address - Street 1:9630 NORRIS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7720
Mailing Address - Country:US
Mailing Address - Phone:318-212-7830
Mailing Address - Fax:
Practice Address - Street 1:2525 VIKING DRIVE
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2058
Practice Address - Country:US
Practice Address - Phone:318-841-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022753207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty