Provider Demographics
NPI:1134394596
Name:THATAYATIKOM, STHORN (MD)
Entity type:Individual
Prefix:
First Name:STHORN
Middle Name:
Last Name:THATAYATIKOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:3000 N ORANGE AVE STE DE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-7613
Practice Address - Country:US
Practice Address - Phone:407-845-8342
Practice Address - Fax:407-845-8343
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114556207RA0201X, 2080P0201X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007647400Medicaid
FLIB733YMedicare PIN