Provider Demographics
NPI:1164407391
Name:HARTLEY, THOMAS MARK (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MARK
Last Name:HARTLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:HARTLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4444 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4136
Mailing Address - Country:US
Mailing Address - Phone:951-682-5661
Mailing Address - Fax:951-686-3758
Practice Address - Street 1:4444 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501
Practice Address - Country:US
Practice Address - Phone:951-682-5661
Practice Address - Fax:951-686-3758
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100628207X00000X
CAG89301207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164407391OtherCOVENTRY
P00455132OtherRAILROAD MEDICARE
18475026OtherBCBS
3076318OtherCIGNA
4364771OtherAETNA
1164407391OtherTRICARE
1093058OtherUNITED HEALTH CARE
MOY363298Medicare PIN
4364771OtherAETNA