Provider Demographics
NPI:1245212943
Name:HAUSAM, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:HAUSAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:81 W ESPERANZA BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-2667
Mailing Address - Country:US
Mailing Address - Phone:520-615-4401
Mailing Address - Fax:520-625-8504
Practice Address - Street 1:1150 WHITEHOUSE CANYON RD
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614
Practice Address - Country:US
Practice Address - Phone:520-625-3691
Practice Address - Fax:520-625-2894
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2012-02-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AR14547208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ820705Medicaid
AZD23695Medicare UPIN
AZ820705Medicaid