Provider Demographics
NPI:1710092184
Name:ELIAS, THOMAS GLENN JR (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:GLENN
Last Name:ELIAS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:T.
Other - Middle Name:GLENN
Other - Last Name:ELIAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2020 GENESEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4219
Mailing Address - Country:US
Mailing Address - Phone:858-616-8400
Mailing Address - Fax:858-569-0741
Practice Address - Street 1:2020 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4219
Practice Address - Country:US
Practice Address - Phone:858-616-8400
Practice Address - Fax:858-569-0741
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45571207P00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G455710Medicaid
CAWG45571AMedicare ID - Type Unspecified
CA00G455710Medicaid