Provider Demographics
NPI:1043235930
Name:THORDARSON, SMARI (MD)
Entity type:Individual
Prefix:
First Name:SMARI
Middle Name:
Last Name:THORDARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 LINCOLNWAY
Mailing Address - Street 2:
Mailing Address - City:LAPORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-2301
Mailing Address - Country:US
Mailing Address - Phone:219-326-2305
Mailing Address - Fax:219-326-2605
Practice Address - Street 1:1007 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LAPORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-2301
Practice Address - Country:US
Practice Address - Phone:219-326-2305
Practice Address - Fax:219-326-2605
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010397472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3213335OtherMEDICAID
F14305Medicare UPIN
IN483980DMedicare ID - Type Unspecified