Provider Demographics
NPI:1790858413
Name:ENG, THOMAS T (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:T
Last Name:ENG
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 1:341 MAGNOLIA AVE
Mailing Address - Street 2:#102
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3331
Mailing Address - Country:US
Mailing Address - Phone:951-371-8109
Mailing Address - Fax:951-272-3936
Practice Address - Street 1:341 MAGNOLIA AVE
Practice Address - Street 2:#102
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3331
Practice Address - Country:US
Practice Address - Phone:951-371-8109
Practice Address - Fax:951-272-3936
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
A040273174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A402730Medicaid
CA00A402730Medicaid
CA00A402730Medicare ID - Type Unspecified