Provider Demographics
NPI:1891807855
Name:LORUNGROCHANA, THAVORN (MD)
Entity Type:Individual
Prefix:DR
First Name:THAVORN
Middle Name:
Last Name:LORUNGROCHANA
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 1:12025 APPLE KNOLL CT
Mailing Address - Street 2:
Mailing Address - City:NORTH POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20878-2374
Mailing Address - Country:US
Mailing Address - Phone:301-840-9482
Mailing Address - Fax:301-840-9482
Practice Address - Street 1:4649 NANNIE HELEN BURROUGHS AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3662
Practice Address - Country:US
Practice Address - Phone:202-398-4700
Practice Address - Fax:202-398-4701
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD7557174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC2219400OtherAETNA HEALTHCARE
DC3220-0001OtherBLUE CROSS BLUE SHIELD
DC274363OtherTRICARE
DC4053222OtherAETNA CHOICE
DC2219400OtherAETNA HEALTHCARE
DCC94006Medicare UPIN