Provider Demographics
NPI:1770505570
Name:THOMAS, CHAVANNES (MD)
Entity Type:Individual
Prefix:
First Name:CHAVANNES
Middle Name:
Last Name:THOMAS
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 1:1028 FORDHAM LN
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1014
Mailing Address - Country:US
Mailing Address - Phone:718-367-4488
Mailing Address - Fax:718-367-0078
Practice Address - Street 1:75 W 190TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-5228
Practice Address - Country:US
Practice Address - Phone:718-367-4488
Practice Address - Fax:718-367-0078
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143387207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00591153Medicaid
NY00591153Medicaid
NY77A441Medicare ID - Type Unspecified