Provider Demographics
NPI:1588845655
Name:THOMAS, RICHARD WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WALLACE
Last Name:THOMAS
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 1:6B CRAGER CT
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:GA
Mailing Address - Zip Code:31408-1314
Mailing Address - Country:US
Mailing Address - Phone:912-856-1363
Mailing Address - Fax:
Practice Address - Street 1:6B CRAGER CT
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:GA
Practice Address - Zip Code:31408-1314
Practice Address - Country:US
Practice Address - Phone:912-856-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-17
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH47608207Q00000X
GA59520207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine