Healthcare Provider Details

I. General information

NPI: 1417940883
Provider Name (Legal Business Name): PRAMUAN THIRASILPA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

948 EBERSOLE BLVD
FOSTORIA OH
44830-1413
US

IV. Provider business mailing address

948 EBERSOLE BLVD
FOSTORIA OH
44830-1413
US

V. Phone/Fax

Practice location:
  • Phone: 419-435-8159
  • Fax: 419-435-8150
Mailing address:
  • Phone: 419-435-8159
  • Fax: 419-435-8150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35034307
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35034307
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: