Provider Demographics
NPI:1669455523
Name:CHRISTIAN, THOMAS WARREN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WARREN
Last Name:CHRISTIAN
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 1:5903 RIDGEWOOD RD
Mailing Address - Street 2:SUITE 430
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3702
Mailing Address - Country:US
Mailing Address - Phone:601-899-3450
Mailing Address - Fax:601-899-3453
Practice Address - Street 1:5903 RIDGEWOOD RD
Practice Address - Street 2:SUITE 430
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3702
Practice Address - Country:US
Practice Address - Phone:601-899-3450
Practice Address - Fax:601-899-3453
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06707207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017537Medicaid
MS00017537Medicaid
MS00017537Medicaid
MS030000012Medicare ID - Type Unspecified