Provider Demographics
NPI:1871685404
Name:JAN, THOMAS FREDERICK (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:FREDERICK
Last Name:JAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5311
Mailing Address - Country:US
Mailing Address - Phone:516-541-1064
Mailing Address - Fax:516-798-9070
Practice Address - Street 1:4200 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5311
Practice Address - Country:US
Practice Address - Phone:516-541-1064
Practice Address - Fax:516-798-9070
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204322204D00000X, 2081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG44762Medicare UPIN
NYTJ05943710Medicare ID - Type Unspecified