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:
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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
StateLicense IDTaxonomies
MI4301076069170100000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM95030004Medicare ID - Type Unspecified
MIH97939Medicare UPIN