Provider Demographics
NPI:1205046034
Name:SEDLOCK, THOMAS ELDEN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ELDEN
Last Name:SEDLOCK
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 1:255 W 88TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1716
Mailing Address - Country:US
Mailing Address - Phone:212-580-8800
Mailing Address - Fax:
Practice Address - Street 1:255 W 88TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-1716
Practice Address - Country:US
Practice Address - Phone:212-580-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102L00000X, 106H00000X
NY1061322084P0800X, 208U00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No208U00000XAllopathic & Osteopathic PhysiciansClinical Pharmacology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00186094046Medicaid
NYTSO654341Medicare ID - Type Unspecified
NY00186094046Medicaid