Provider Demographics
NPI:1053300863
Name:HEADSTREAM, THOMAS LEE (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEE
Last Name:HEADSTREAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5409
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79608-5409
Mailing Address - Country:US
Mailing Address - Phone:325-793-5130
Mailing Address - Fax:325-670-5133
Practice Address - Street 1:1665 ANTILLEY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5265
Practice Address - Country:US
Practice Address - Phone:325-793-5130
Practice Address - Fax:325-793-5133
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2148207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103700402Medicaid
TX838061Medicare PIN
TXB23372Medicare UPIN