Provider Demographics
NPI:1891799128
Name:THOMAS, MARY ISSAC (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ISSAC
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:ISSAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 861295
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-1295
Mailing Address - Country:US
Mailing Address - Phone:813-636-2000
Mailing Address - Fax:813-636-2020
Practice Address - Street 1:3550 W. WATERS AVENUE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2716
Practice Address - Country:US
Practice Address - Phone:813-886-8899
Practice Address - Fax:813-443-8162
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047669200Medicaid
FL05832UMedicare PIN
FLD61296Medicare UPIN