Provider Demographics
NPI:1043416506
Name:THOMAS, SHAWN WAYNE (DO)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:WAYNE
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 864074
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-4074
Mailing Address - Country:US
Mailing Address - Phone:386-254-4199
Mailing Address - Fax:386-947-4680
Practice Address - Street 1:311 N CLYDE MORRIS BLVD STE 360
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2757
Practice Address - Country:US
Practice Address - Phone:386-254-4199
Practice Address - Fax:386-947-4680
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S013305208800000X
FLOS10348208800000X
WV2603208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810024050Medicaid
FL000282900Medicaid
WVWV1630 B441Medicare PIN
FLAL777WMedicare PIN