Provider Demographics
NPI:1477564466
Name:ELDER, THOMAS M III (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:ELDER
Suffix:III
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 1:19887 JUNIPER RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-8713
Mailing Address - Country:US
Mailing Address - Phone:760-247-8411
Mailing Address - Fax:760-247-8411
Practice Address - Street 1:19887 JUNIPER RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-8713
Practice Address - Country:US
Practice Address - Phone:760-247-8411
Practice Address - Fax:760-247-8411
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGFE25277207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42599Medicare UPIN