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: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 CHEROKEE ST NE
MARIETTA GA
30060-7279
US

IV. Provider business mailing address

653 CHEROKEE ST NE
MARIETTA GA
30060-7279
US

V. Phone/Fax

Practice location:
  • Phone: 770-419-1393
  • Fax:
Mailing address:
  • Phone: 770-419-1393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number112875
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME144797
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: