MEDICARE: PHOUTTHASONE THIRAKUL

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	A125018	CA

General Provider Information

NPI Number	:	1760800460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHOUTTHASONE THIRAKUL

Provider Business Mailing Address
First Line	:	11025 N 46TH ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33617-2000
Country	:	US
Telephone Number	:	813-914-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	11025 N 46TH ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33617-2000
Country	:	US
Telephone Number	:	813-914-4500
Fax Number	:

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

Provider Enumeration Date	:	04/01/2014
Last Update Date	:	06/16/2015

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Directions to “ PHOUTTHASONE THIRAKUL ” Practice Location

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