Provider Demographics
NPI:1265448195
Name:BOHLMANN, THOMAS DALE (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DALE
Last Name:BOHLMANN
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:P.O. BOX 60790
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-6790
Mailing Address - Country:US
Mailing Address - Phone:626-204-6747
Mailing Address - Fax:626-396-0851
Practice Address - Street 1:1250 16TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1249
Practice Address - Country:US
Practice Address - Phone:310-319-4610
Practice Address - Fax:310-576-6025
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61792207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G617920Medicaid
CA00G617920OtherBLUE SHIELD
CA00G617920OtherBLUE SHIELD
CA00G617920Medicaid