Provider Demographics
NPI:1104835925
Name:THOMASSEN, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:THOMASSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2800 E COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4229
Mailing Address - Country:US
Mailing Address - Phone:954-771-0200
Mailing Address - Fax:954-208-5171
Practice Address - Street 1:2800 E COMMERCIAL BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4229
Practice Address - Country:US
Practice Address - Phone:954-771-0200
Practice Address - Fax:954-208-5171
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 95272208200000X
DCMD 33673208200000X
VA0101231653208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276131900Medicaid
FL276131900Medicaid