Provider Demographics
NPI:1932134764
Name:MAUSBACH, THOMAS W (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:MAUSBACH
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 1:2701 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3602
Mailing Address - Country:US
Mailing Address - Phone:701-234-3620
Mailing Address - Fax:
Practice Address - Street 1:2701 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3602
Practice Address - Country:US
Practice Address - Phone:701-234-3620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3790208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND592087600Medicaid
NDND100008OtherLHS#
ND1201795OtherMEDICA #
ND1201198OtherMEDICA #
ND676635OtherAMERICA'S PPO/ARAZ #
ND1201202OtherMEDICA #
ND50288MAOtherMNBS #
ND91422MAOtherMNBS #
NDDA9011015564OtherPREFERRED ONE #
ND141926OtherUCARE #
ND21590OtherNDBS #
ND1201197OtherMEDICA #
NDHP19527OtherHEALTHPARTNERS #
ND12392Medicaid
NDND100008OtherLHS#
ND1201795OtherMEDICA #
ND676635OtherAMERICA'S PPO/ARAZ #
ND21590OtherNDBS #