Provider Demographics
NPI:1760468599
Name:VENDEGNA, THOMAS R (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:R
Last Name:VENDEGNA
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 1:1304 ELLA ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4165
Mailing Address - Country:US
Mailing Address - Phone:805-549-9555
Mailing Address - Fax:805-549-0444
Practice Address - Street 1:1304 ELLA ST STE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4165
Practice Address - Country:US
Practice Address - Phone:805-549-9555
Practice Address - Fax:805-549-0444
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83698207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G836980Medicaid
CA00G836980Medicaid
290010833Medicare PIN
WG83698BMedicare ID - Type Unspecified