Provider Demographics
NPI:1619104213
Name:THOMAS, TINA THERESA (MD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:THERESA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PROSPECT AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1941
Mailing Address - Country:US
Mailing Address - Phone:551-996-2625
Mailing Address - Fax:551-996-2021
Practice Address - Street 1:20 PROSPECT AVE STE 408
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1941
Practice Address - Country:US
Practice Address - Phone:551-996-2625
Practice Address - Fax:551-996-2021
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105996208600000X, 2086S0102X, 2086S0120X, 390200000X
NJ25MA10210400208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program