Provider Demographics
NPI:1861505281
Name:THOMAS, MARY MEENA (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MEENA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 EAST MAIN STREET
Mailing Address - Street 2:SUITE 21
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706
Mailing Address - Country:US
Mailing Address - Phone:631-968-8288
Mailing Address - Fax:631-968-8268
Practice Address - Street 1:375 EAST MAIN STREET
Practice Address - Street 2:SUITE 21
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-968-8288
Practice Address - Fax:631-968-8268
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216878207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02590774Medicaid
NY02590774Medicaid
I02391Medicare UPIN