Provider Demographics
NPI:1669466462
Name:FABIAN, THOMAS M (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:FABIAN
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 1:2625 TAMIAMI TRL UNIT 1
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6403
Mailing Address - Country:US
Mailing Address - Phone:877-277-4646
Mailing Address - Fax:941-235-4642
Practice Address - Street 1:2625 TAMIAMI TRL
Practice Address - Street 2:UNIT 1
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6478
Practice Address - Country:US
Practice Address - Phone:941-235-4646
Practice Address - Fax:941-235-4655
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME469012085R0202X
MDD761302085R0202X
OH25.0002702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00195923FOtherRAILROAD PROVIDER NUMBER
FL08146WMedicare ID - Type Unspecified
FLP00195923FOtherRAILROAD PROVIDER NUMBER