Provider Demographics
NPI:1346860368
Name:TOM, MICHAEL JASON (RT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JASON
Last Name:TOM
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2418
Mailing Address - Country:US
Mailing Address - Phone:718-267-4255
Mailing Address - Fax:
Practice Address - Street 1:2510 30TH AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11102-2418
Practice Address - Country:US
Practice Address - Phone:718-267-4255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0120692471V0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471V0106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular-Interventional Technology