Provider Demographics
NPI:1902837289
Name:DEMEESTER, TOM RYAN (MD)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:RYAN
Last Name:DEMEESTER
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 1:1510 SAN PABLO ST
Mailing Address - Street 2:SUITE 514
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-5324
Mailing Address - Country:US
Mailing Address - Phone:323-442-5910
Mailing Address - Fax:323-442-6798
Practice Address - Street 1:1510 SAN PABLO ST
Practice Address - Street 2:SUITE 514
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5324
Practice Address - Country:US
Practice Address - Phone:323-442-5910
Practice Address - Fax:323-442-6798
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42820208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C428200OtherBLUE SHIELD PIN
CA020023696OtherMEDICARE RAILROAD PIN
CA00C428200C29OtherCAL OPTIMA PIN
CA00C428200Medicaid
CA00C428200C29OtherCAL OPTIMA PIN
CABO024ZMedicare PIN
CAWC42820AMedicare PIN