Provider Demographics
NPI:1134124662
Name:NUSSDORFER, THOMAS C (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:C
Last Name:NUSSDORFER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3074 N US 31 S
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4533
Mailing Address - Country:US
Mailing Address - Phone:231-929-1234
Mailing Address - Fax:231-935-0984
Practice Address - Street 1:3074 N US 31 S
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4533
Practice Address - Country:US
Practice Address - Phone:231-929-1234
Practice Address - Fax:231-935-0984
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301046246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383530686052OtherCOMMUNITY CHOICE
MI0B81066OtherBLUE CARE NETWORK
MI1134124662OtherTHOMAS NUSSDORFER MD
MI1134124662Medicaid
MI349386200OtherUS POSTAL
MI4391565Medicaid
MI700B810660OtherBLUE CARE NETWORK
MIA75289OtherPRIORITY HEALTH
MI000000008993OtherCAP HEALTH
MI121591OtherUNITED HEALTH
MI132959OtherCARE CHOICES
MI1851344964OtherCORP NPI
MI383530686OtherPPOM
MI1134124662OtherINDIVIDUAL NPI NUMBER
MI080189368OtherRAILROAD MEDICARE
MI080189368OtherRAILROAD MEDICARE
MIA75289OtherPRIORITY HEALTH
MIA75289Medicare UPIN