MEDICARE: STHORN THATAYATIKOM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RA0201X	Allergy & Immunology (Internal Medicine) Physician	ME114556	FL
2	2080P0201X	Pediatric Allergy/Immunology Physician	ME114556	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134394596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STHORN THATAYATIKOM MD

Provider Business Mailing Address
First Line	:	PO BOX 191
Second Line	:	PROVIDER ENROLLMENT
City	:	ROCKLAND
State	:	DE
Zip	:	19732-0191
Country	:	US
Telephone Number	:	302-651-6212
Fax Number	:	302-651-4945

Provider Business Practice Location Address
First Line	:	3000 N ORANGE AVE STE DE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-7613
Country	:	US
Telephone Number	:	407-845-8342
Fax Number	:	407-845-8343

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2008
Last Update Date	:	11/21/2023

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Directions to “ STHORN THATAYATIKOM MD” Practice Location

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