Provider Demographics
NPI:1104011196
Name:GAULT, THOMAS D (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:D
Last Name:GAULT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5269 JONESTOWN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-5002
Mailing Address - Country:US
Mailing Address - Phone:717-657-1620
Mailing Address - Fax:717-540-1540
Practice Address - Street 1:5269 JONESTOWN RD STE 101
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-5002
Practice Address - Country:US
Practice Address - Phone:717-657-1620
Practice Address - Fax:717-540-1540
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGA422548Medicare PIN