Provider Demographics
NPI: | 1750304796 |
---|---|
Name: | THOMAS, MARK WILLIAM (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MARK |
Middle Name: | WILLIAM |
Last Name: | THOMAS |
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: | 19186 CHELTON DR |
Mailing Address - Street 2: | |
Mailing Address - City: | BEVERLY HILLS |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48025-5212 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 248-625-9755 |
Mailing Address - Fax: | 248-620-9334 |
Practice Address - Street 1: | 7210 N MAIN ST STE 205 |
Practice Address - Street 2: | |
Practice Address - City: | CLARKSTON |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48346-1575 |
Practice Address - Country: | US |
Practice Address - Phone: | 248-625-9755 |
Practice Address - Fax: | 248-620-9334 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-25 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 4301076069 | 170100000X, 208000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 170100000X | Other Service Providers | Medical Genetics, Ph.D. Medical Genetics | |
Not Answered | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MI | M95030004 | Medicare ID - Type Unspecified | |
MI | H97939 | Medicare UPIN |