Healthcare Provider Details

I. General information

NPI: 1366650236
Provider Name (Legal Business Name): AKALUCK THATAYATIKOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N ORANGE AVE STE 586
ORLANDO FL
32804-4603
US

IV. Provider business mailing address

2501 N ORANGE AVE STE 586
ORLANDO FL
32804-4603
US

V. Phone/Fax

Practice location:
  • Phone: 407-821-3545
  • Fax: 407-821-3546
Mailing address:
  • Phone: 407-821-3545
  • Fax: 407-821-3546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number2006035310
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License NumberME114452
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: