Provider Demographics
NPI:1942952536
Name:THOMAS, DWAN SAMUEL SR (MEDICAID PROVIDER)
Entity Type:Individual
Prefix:MR
First Name:DWAN
Middle Name:SAMUEL
Last Name:THOMAS
Suffix:SR
Gender:M
Credentials:MEDICAID PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 NW 45TH LN
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34475-9546
Mailing Address - Country:US
Mailing Address - Phone:352-433-8457
Mailing Address - Fax:
Practice Address - Street 1:2 REDWOOD TRCE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34472-6297
Practice Address - Country:US
Practice Address - Phone:352-433-8457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker