Provider Demographics
NPI:1942226535
Name:MCINTOSH, THOMAS GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GEORGE
Last Name:MCINTOSH
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 1:1231 MOCKINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-2812
Mailing Address - Country:US
Mailing Address - Phone:817-251-6362
Mailing Address - Fax:
Practice Address - Street 1:1231 MOCKINGBIRD DR
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-2812
Practice Address - Country:US
Practice Address - Phone:817-251-6362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42087207Q00000X
KY31833207Q00000X
TXD9033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82587361Medicaid
CO82587361Medicaid
CO061844Medicare ID - Type Unspecified