Provider Demographics
NPI:1710574280
Name:THOMAS, MILDRED ROMAIN
Entity Type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:ROMAIN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MILDRED
Other - Middle Name:ROMAIN
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4658 BOUDINOT ST LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-4521
Mailing Address - Country:US
Mailing Address - Phone:215-313-0320
Mailing Address - Fax:215-324-1903
Practice Address - Street 1:4658 BOUDINOT ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-4521
Practice Address - Country:US
Practice Address - Phone:215-313-0320
Practice Address - Fax:215-324-1903
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAC70579224900000X, 224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Multi-Specialty