Provider Demographics
NPI:1861507782
Name:DAKE, THOMAS S (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:DAKE
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 1:2308 COUNTRY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-5172
Mailing Address - Country:US
Mailing Address - Phone:931-388-6059
Mailing Address - Fax:
Practice Address - Street 1:2308 COUNTRY CLUB LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-5172
Practice Address - Country:US
Practice Address - Phone:931-388-6059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7928207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3710084Medicaid
TN3152490Medicaid
TN31524901Medicaid
TN3151739OtherBCBSTN
TN3710089Medicaid
TN3710084Medicaid
TNB02404Medicare UPIN
TN31524901Medicaid
TN3152490Medicaid
3710089Medicare PIN
3152494Medicare PIN
TN080162133Medicare PIN