Basic Information
| Provider Information | |||||||||
| NPI: | 1588627293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KASEMSRI | ||||||||
| FirstName: | THIVAKORN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5219 CITY BANK PKWY STE 35 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794073545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067610333 | ||||||||
| FaxNumber: | 8067820097 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 INDIANA AVE | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794153364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067758813 | ||||||||
| FaxNumber: | 8067759182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | L0841 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | L0841 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 144993601 | 05 | TX | MEDICAID |