Provider Demographics
NPI:1134102973
Name:DIGERONIMO, THOMAS A (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:DIGERONIMO
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 1:3302 W BAKER ST
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-2851
Mailing Address - Country:US
Mailing Address - Phone:813-752-1336
Mailing Address - Fax:813-754-6914
Practice Address - Street 1:3302 W BAKER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-2851
Practice Address - Country:US
Practice Address - Phone:813-752-1336
Practice Address - Fax:813-754-6914
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00548742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055884200Medicaid
FLF03395Medicare UPIN
FL055884200Medicaid