Provider Demographics
NPI:1891713582
Name:LAUDERMAN, THOMAS A (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:LAUDERMAN
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 1:255 SUNBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WV
Mailing Address - Zip Code:26426-8400
Mailing Address - Country:US
Mailing Address - Phone:304-782-3000
Mailing Address - Fax:304-782-3003
Practice Address - Street 1:255 SUNBRIDGE DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:WV
Practice Address - Zip Code:26426-8400
Practice Address - Country:US
Practice Address - Phone:304-782-3000
Practice Address - Fax:304-782-3003
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1433207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0010736000Medicaid
WVLA0824632Medicare PIN
WVF84466Medicare UPIN