Healthcare Provider Details

I. General information

NPI: 1104731256
Provider Name (Legal Business Name): THUNYALUCK JIWANAROM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON ROAD
ATLANTA GA
30322
US

IV. Provider business mailing address

DEPARTMENT OF OPHTHALMOLOGY, FACULTY OF MEDICINE 110 INTAWAROROT ROAD, SUTHEP SUBDISTRICT
MUEANG CHIANG MAI DISTRICT CHIANG MAI
50200
TH

V. Phone/Fax

Practice location:
  • Phone: 404-778-3324
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: