Provider Demographics
NPI:1942275250
Name:THOMAS, MARIAM R (MD)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:R
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17435 TUSCAN DR
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-1056
Mailing Address - Country:US
Mailing Address - Phone:314-913-3590
Mailing Address - Fax:
Practice Address - Street 1:17435 TUSCAN DR
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-1056
Practice Address - Country:US
Practice Address - Phone:314-913-3590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA938682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A938680Medicaid
MO2005029373OtherSTATE MEDICAL LICENSE
CA00A938680Medicaid
CAWA93868AMedicare PIN