Provider Demographics
NPI:1093725855
Name:THOMAS, SEAN R (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:R
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55585 29 PALMS HWY
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-2505
Mailing Address - Country:US
Mailing Address - Phone:760-228-3366
Mailing Address - Fax:760-228-3369
Practice Address - Street 1:55585 29 PALMS HWY
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-2505
Practice Address - Country:US
Practice Address - Phone:760-228-3366
Practice Address - Fax:760-228-3369
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60305208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA60305OtherLICENSE #
CA00A603050Medicaid
CAH10323Medicare UPIN
CACA060ZMedicare PIN