Provider Demographics
NPI:1952491771
Name:THOYAKULATHU, SAM G (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:G
Last Name:THOYAKULATHU
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 1:1211 EAST SIXTH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418
Mailing Address - Country:US
Mailing Address - Phone:903-640-1422
Mailing Address - Fax:903-640-4275
Practice Address - Street 1:1211 EAST SIXTH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418
Practice Address - Country:US
Practice Address - Phone:903-640-1422
Practice Address - Fax:903-640-4275
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5496207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0017EROtherBC
00858NMedicare ID - Type Unspecified
TX0017EROtherBC