Provider Demographics
NPI:1790787059
Name:THOMAS, THOMAS CORDELL (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CORDELL
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 1:110 WESTWOODS DR.
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-1218
Mailing Address - Country:US
Mailing Address - Phone:816-781-6127
Mailing Address - Fax:
Practice Address - Street 1:110 WESTWOODS DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-1181
Practice Address - Country:US
Practice Address - Phone:816-781-6127
Practice Address - Fax:816-792-2265
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO28478207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205285901Medicaid
MO01832015OtherBCBS
MOC50168Medicare UPIN
MOB09000Medicare PIN