Provider Demographics
NPI:1073629507
Name:WILCOX, THOMAS MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MATTHEW
Last Name:WILCOX
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 1:5450 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-415-5399
Mailing Address - Fax:303-297-5808
Practice Address - Street 1:4820 RIVERBEND RD STE 100
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-2618
Practice Address - Country:US
Practice Address - Phone:303-415-5399
Practice Address - Fax:303-297-5808
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0035574207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01355742Medicaid
COCO305474Medicare PIN
COF05623Medicare UPIN
F05623Medicare UPIN
COF05623Medicare UPIN