Provider Demographics
NPI:1982015616
Name:INTHAPHOM, TRUC (MD)
Entity Type:Individual
Prefix:
First Name:TRUC
Middle Name:
Last Name:INTHAPHOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27700 NORTHWEST FWY STE 440
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-6767
Mailing Address - Country:US
Mailing Address - Phone:832-334-4011
Mailing Address - Fax:832-334-4009
Practice Address - Street 1:27700 NORTHWEST FWY STE 440
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-6767
Practice Address - Country:US
Practice Address - Phone:832-334-4011
Practice Address - Fax:832-334-4009
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR3236208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty