Provider Demographics
NPI:1609842897
Name:KEFALAS, THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:KEFALAS
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 1:215 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3615
Mailing Address - Country:US
Mailing Address - Phone:218-326-1274
Mailing Address - Fax:
Practice Address - Street 1:215 SE 2ND AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3615
Practice Address - Country:US
Practice Address - Phone:218-326-1274
Practice Address - Fax:218-326-9787
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2009-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN447432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN250493600Medicaid
MN260002119Medicare ID - Type Unspecified
MN250493600Medicaid