Provider Demographics
NPI:1417053422
Name:BLAIR, THOMAS L (INTERNAL MEDICINE)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:BLAIR
Suffix:
Gender:M
Credentials:INTERNAL MEDICINE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:725 W LA VETA AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4403
Mailing Address - Country:US
Mailing Address - Phone:714-538-7060
Mailing Address - Fax:714-538-0594
Practice Address - Street 1:725 W LA VETA AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4403
Practice Address - Country:US
Practice Address - Phone:714-538-7060
Practice Address - Fax:714-538-0594
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG45575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG45575OtherLICENSE
CAB57638Medicare UPIN