Provider Demographics
NPI:1487651311
Name:SULT, THOMAS ALLEN (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ALLEN
Last Name:SULT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:MN
Mailing Address - Zip Code:56273-0607
Mailing Address - Country:US
Mailing Address - Phone:320-347-1212
Mailing Address - Fax:320-347-1200
Practice Address - Street 1:7900 CHAPIN DR NE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:MN
Practice Address - Zip Code:56273-8538
Practice Address - Country:US
Practice Address - Phone:320-347-1212
Practice Address - Fax:320-347-1200
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN169318P539OtherUCARE
MN1770646937OtherUNICARE
MN1770646937OtherPREFERRED ONE
MN31T18INOtherBCBS
MN031216004OtherPRIME WEST
MN534225200Medicaid
MN01-09668OtherMEDICA
MN1770646937OtherAETNA
MN1770646937OtherHUMANA
MN1770646937OtherSELECT CARE
MNHP11557OtherHEALTH PARTNERS
MN1770646937OtherTRICARE
MN110486P539OtherUCARE
MN1770646937OtherMMSI
MN31T18INOtherCCS
MN376SISUOtherBLUE CROSS BLUE SHEILD
MN9823046OtherMEDICA
MNMR143-1001629OtherPREFERRED ONE
MN1219767OtherARAZ
MN1770646937OtherUNITED HEALTHCARE
MN376SISUOtherBLUE CROSS BLUE SHEILD
MN080011485Medicare UPIN