Healthcare Provider Details

I. General information

NPI: 1457706723
Provider Name (Legal Business Name): SIRIPONG ROJANASTHIEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 GREENWOOD BLVD
LAKE MARY FL
32746-5404
US

IV. Provider business mailing address

1755 S GRAND BLVD DEPARTMENT OF OPHTHALMOLOGY
SAINT LOUIS MO
63104
US

V. Phone/Fax

Practice location:
  • Phone: 407-333-5111
  • Fax:
Mailing address:
  • Phone: 314-256-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME144797
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: