Provider Demographics
NPI:1164179537
Name:THOMAS, ALONZO MONTEZ
Entity Type:Individual
Prefix:
First Name:ALONZO
Middle Name:MONTEZ
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43106-9009
Mailing Address - Country:US
Mailing Address - Phone:937-600-2781
Mailing Address - Fax:
Practice Address - Street 1:42 WAYNE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGBURG
Practice Address - State:OH
Practice Address - Zip Code:43106-9009
Practice Address - Country:US
Practice Address - Phone:937-600-2781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH17500000XOtherPEER SPECIALIST