Provider Demographics
NPI:1790742054
Name:POWELL, THOMAS R (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1140 W LA VETA AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4223
Mailing Address - Country:US
Mailing Address - Phone:714-245-0492
Mailing Address - Fax:714-245-0794
Practice Address - Street 1:1140 W LA VETA AVE STE 106
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4223
Practice Address - Country:US
Practice Address - Phone:714-245-0492
Practice Address - Fax:714-245-0494
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2010-01-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG25187207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A42563Medicare UPIN