Provider Demographics
NPI:1821034125
Name:CUNNINGHAM, THOMAS M (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:CUNNINGHAM
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 1:7442 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4331
Mailing Address - Country:US
Mailing Address - Phone:707-318-9256
Mailing Address - Fax:707-823-3956
Practice Address - Street 1:7442 PALM AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4331
Practice Address - Country:US
Practice Address - Phone:707-318-9256
Practice Address - Fax:707-823-3956
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40423174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G404230Medicaid
CA00G404230Medicare ID - Type Unspecified
CA00G404230Medicaid