Provider Demographics
NPI:1760483689
Name:MUTTON, THOMAS PAUL (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PAUL
Last Name:MUTTON
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 1:1900 S HAWTHORNE RD
Mailing Address - Street 2:SUITE 480
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3913
Mailing Address - Country:US
Mailing Address - Phone:336-765-0155
Mailing Address - Fax:336-765-5494
Practice Address - Street 1:1900 S HAWTHORNE RD
Practice Address - Street 2:SUITE 480
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3913
Practice Address - Country:US
Practice Address - Phone:336-765-0155
Practice Address - Fax:336-765-5494
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2020-10-25
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
NC18688174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
61648OtherBLUE CROSS/BLUESHIELD
122902OtherWELLPATH
1319922OtherCIGNA HEALTHCARE
125882OtherAETNA
546165OtherUHC
28536OtherMEDCOST
NC8961648Medicaid
2072030OtherFIRST HEALTH GROUP
125882OtherAETNA
NC5724780001Medicare NSC
546165OtherUHC
NC202451Medicare PIN