Healthcare Provider Details

I. General information

NPI: 1558926071
Provider Name (Legal Business Name): THANITA THONGTAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S LANDMARK AVE
BLOOMINGTON IN
47403-3239
US

IV. Provider business mailing address

5520 LEONARDO DA VINCI STE 100
EDINBURG TX
78539-1422
US

V. Phone/Fax

Practice location:
  • Phone: 812-355-6900
  • Fax:
Mailing address:
  • Phone: 956-362-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01095800A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01095800A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: