Provider Demographics
NPI:1578821369
Name:BARRY, THOMAS JOHN
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:BARRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17331 WILD ROSE LANE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-4653
Mailing Address - Country:US
Mailing Address - Phone:714-841-6360
Mailing Address - Fax:714-840-8900
Practice Address - Street 1:16582 GOTHARD STREET
Practice Address - Street 2:SUITE C
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-8559
Practice Address - Country:US
Practice Address - Phone:714-841-6360
Practice Address - Fax:714-840-8900
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55154332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5852580001Medicare UPIN