Provider Demographics
NPI:1043362601
Name:THOMAS, MARK B (DC, DABCI)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DC, DABCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E WHITEAKER AVE
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1648
Mailing Address - Country:US
Mailing Address - Phone:541-942-5024
Mailing Address - Fax:541-942-0598
Practice Address - Street 1:500 E WHITEAKER AVE
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1648
Practice Address - Country:US
Practice Address - Phone:541-942-5024
Practice Address - Fax:541-942-0598
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR271279111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067246002OtherBLUE CROSS
OR067246000OtherBLUE CROSS
OR231779Medicaid
OR067246000OtherBLUE CROSS
OR067246002OtherBLUE CROSS