Provider Demographics
NPI:1609893692
Name:TOMMASO, CARL L (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:L
Last Name:TOMMASO
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057211207R00000X, 207RC0000X, 207RI0011X
TXS8499207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL57016OtherMEDICARE PIN LOCALITY 16
IL04915267OtherBLUE CROSS BLUE SHIELD
ILL54692OtherMEDICARE PIN LOCALITY 15
IL36057211Medicaid
IL234170Medicare ID - Type UnspecifiedLOCALITY 16
ILL57016OtherMEDICARE PIN LOCALITY 16
ILC49047Medicare UPIN
ILCB4276Medicare ID - Type UnspecifiedRAILROAD MEDICARE