| Doctor Name: | DR. SOMPHONG THITARAM |
| NPI Number: | 1063504074 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MD |
| License Number: | 15046 |
| Business Practice Address: | 2550 Windy Hill Rd Se 106 Marietta, GA - 300678665 |
| Business Phone Number: | 7709554314 |
| Business Fax Number: | 7709554315 |
| Mailing Address: | 2550 Windy Hill Rd Se, 106 MARIETTA |
| State: | GA |
| Postal Code: | 300678665 |
| Phone Number: | 7709554314 |
| Fax Number: | 7709554315 |
| NPI Enumeration Date: | 09/28/2006 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 15046 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |