Provider Demographics
NPI:1629033980
Name:THOMAS, THERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
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 1:1210 CHUCK DAWLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4186
Mailing Address - Country:US
Mailing Address - Phone:843-971-1955
Mailing Address - Fax:843-974-8044
Practice Address - Street 1:1210 CHUCK DAWLEY BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4186
Practice Address - Country:US
Practice Address - Phone:843-971-1955
Practice Address - Fax:843-974-8044
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17520208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC175205Medicaid