Provider Demographics
NPI:1861664435
Name:PATHOM THAVARADHARA MD PA
Entity Type:Organization
Organization Name:PATHOM THAVARADHARA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATHOM
Authorized Official - Middle Name:
Authorized Official - Last Name:THAVARADHARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-669-2900
Mailing Address - Street 1:100 W 30TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PAMPA
Mailing Address - State:TX
Mailing Address - Zip Code:79065-2814
Mailing Address - Country:US
Mailing Address - Phone:806-669-2900
Mailing Address - Fax:806-669-2031
Practice Address - Street 1:100 W 30TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:PAMPA
Practice Address - State:TX
Practice Address - Zip Code:79065-2814
Practice Address - Country:US
Practice Address - Phone:806-669-2900
Practice Address - Fax:806-669-2031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8581207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0012LMOtherBLUE CROSS/BLUE SHIELD
TX167272701Medicaid
TXDD1161OtherRAILROAD MEDICARE, PALMETTO GBA
TXDD1161OtherRAILROAD MEDICARE, PALMETTO GBA