Provider Demographics
NPI:1104837509
Name:JOHN MICHAEL THOMASSEN MD PA
Entity Type:Organization
Organization Name:JOHN MICHAEL THOMASSEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:THOMASSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-771-0200
Mailing Address - Street 1:2800 E COMMERCIAL BLVD
Mailing Address - Street 2:
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 1:1754 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-5721
Practice Address - Country:US
Practice Address - Phone:954-771-0200
Practice Address - Fax:954-208-5171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 95272208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ0618Medicare PIN