Provider Demographics
NPI:1760474712
Name:THOMAS, ROGER P (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:P
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:904-824-2226
Practice Address - Street 1:307 E NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4576
Practice Address - Country:US
Practice Address - Phone:321-729-8223
Practice Address - Fax:321-729-6252
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME117289208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009391900Medicaid
FLHO318ZMedicare PIN