Healthcare Provider Details

I. General information

NPI: 1134394596
Provider Name (Legal Business Name): STHORN THATAYATIKOM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N ORANGE AVE STE DE
ORLANDO FL
32804-7613
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 407-845-8342
  • Fax: 407-845-8343
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberME114556
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberME114556
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: