Provider Demographics
NPI:1073556635
Name:DEGENHARDT, THOMAS C (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:C
Last Name:DEGENHARDT
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 1:1405 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4557
Mailing Address - Country:US
Mailing Address - Phone:707-546-1922
Mailing Address - Fax:707-546-1987
Practice Address - Street 1:1405 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4557
Practice Address - Country:US
Practice Address - Phone:707-546-1922
Practice Address - Fax:707-546-1987
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25938207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG25938OtherLICENSE
CA00G259380Medicaid
CA00G259380OtherCIGNA DME
A42844Medicare UPIN
00G259381Medicare PIN
CA00G259380Medicaid