Provider Demographics
NPI:1760483622
Name:WIARD, THOMAS DAWSON (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DAWSON
Last Name:WIARD
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 1:947 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5716
Mailing Address - Country:US
Mailing Address - Phone:970-249-2421
Mailing Address - Fax:970-249-8897
Practice Address - Street 1:947 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5716
Practice Address - Country:US
Practice Address - Phone:970-249-2421
Practice Address - Fax:970-249-8897
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28168208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01281682Medicaid
CO01281682Medicaid
E39566Medicare UPIN