Provider Demographics
NPI:1013013093
Name:DAHLBERG, THOMAS E (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:DAHLBERG
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 1:3322 S CAMPBELL AVE STE T-1
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4980
Mailing Address - Country:US
Mailing Address - Phone:417-220-4480
Mailing Address - Fax:417-900-2992
Practice Address - Street 1:3322 S CAMPBELL AVE STE T-1
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-4980
Practice Address - Country:US
Practice Address - Phone:417-220-4480
Practice Address - Fax:417-414-0017
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD104392207QH0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500128969Medicaid
080170409OtherRR MEDICARE
MO1013013093Medicaid
MO207984428Medicaid
MO207984428Medicaid
080170409OtherRR MEDICARE
MO001050115Medicare ID - Type Unspecified
MO501150024Medicare PIN