Provider Demographics
NPI:1225136179
Name:PEARSON, THOMAS ROBERT (MSPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROBERT
Last Name:PEARSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3576 IVY DR
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-3314
Mailing Address - Country:US
Mailing Address - Phone:516-935-4456
Mailing Address - Fax:516-739-4909
Practice Address - Street 1:201 I U WILLETS RD
Practice Address - Street 2:
Practice Address - City:ALBERTSON
Practice Address - State:NY
Practice Address - Zip Code:11507-1516
Practice Address - Country:US
Practice Address - Phone:516-739-4900
Practice Address - Fax:516-739-4909
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0217521174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00274415Medicaid
NY330246Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER