Provider Demographics
NPI:1114035243
Name:FEDERICO, THOMAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:FEDERICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 GOLD SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-6333
Mailing Address - Country:US
Mailing Address - Phone:407-697-4345
Mailing Address - Fax:
Practice Address - Street 1:310 GOLD CREEK TRL
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-5435
Practice Address - Country:US
Practice Address - Phone:770-926-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047275207Q00000X
GA065543207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
47762OtherBCBS
47762OtherBCBS
B84836Medicare UPIN