Provider Demographics
NPI:1114960861
Name:HIROSE, THOMAS G (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:HIROSE
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 1:24407 CALLE DE LA LOUISA STE 100
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3650
Mailing Address - Country:US
Mailing Address - Phone:949-310-5700
Mailing Address - Fax:310-373-0600
Practice Address - Street 1:24407 CALLE DE LA LOUISA STE 100
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3650
Practice Address - Country:US
Practice Address - Phone:949-581-0555
Practice Address - Fax:949-581-7555
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66676207ZB0001X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G666760Medicaid
CAWG66676CMedicare PIN
CA00G666760Medicaid
CAWG66676AMedicare PIN
CAG20714Medicare UPIN
CAWG66676DMedicare PIN
CAWG66676LMedicare PIN
CAWG66676GMedicare PIN