Provider Demographics
NPI:1306825500
Name:STATON, THOMAS WALDON (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WALDON
Last Name:STATON
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 1:1203 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-2433
Mailing Address - Country:US
Mailing Address - Phone:618-524-3795
Mailing Address - Fax:618-524-3211
Practice Address - Street 1:1203 W 10TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2433
Practice Address - Country:US
Practice Address - Phone:618-524-3795
Practice Address - Fax:618-524-3211
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036086549207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL000006400037OtherBCBS OF ILLINOIS
IL036086549-3Medicaid
KY000000042813OtherANTHEM BCBS OF KENTUCKY
IL036086549Medicaid
080099679OtherRAILROAD MEDICARE
KY64281678Medicaid
080099679OtherRAILROAD MEDICARE
KY000000042813OtherANTHEM BCBS OF KENTUCKY
IL036086549-3Medicaid
ILL40889Medicare PIN