Provider Demographics
NPI:1497864698
Name:THOMAS, STEFANIE MONIQUE (DPM)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:MONIQUE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 HWY 80 WEST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056
Mailing Address - Country:US
Mailing Address - Phone:601-926-1500
Mailing Address - Fax:601-926-1502
Practice Address - Street 1:705 HWY 80 WEST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056
Practice Address - Country:US
Practice Address - Phone:601-926-1500
Practice Address - Fax:601-926-1502
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80151213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06981282Medicaid
MS480000160Medicare ID - Type Unspecified
MS06981282Medicaid