Provider Demographics
NPI:1538102058
Name:ERNST, THOMAS N (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:N
Last Name:ERNST
Suffix:
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:PO BOX 1420
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-0400
Mailing Address - Country:US
Mailing Address - Phone:541-548-2164
Mailing Address - Fax:541-548-0534
Practice Address - Street 1:211 NW LARCH AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1357
Practice Address - Country:US
Practice Address - Phone:541-548-2164
Practice Address - Fax:541-548-0534
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23788208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10949202OtherCAQH ID
OR286658Medicaid
ORR157574Medicare PIN