Provider Demographics
NPI:1952660359
Name:THOMAS, JANTIRA TARA (DO)
Entity Type:Individual
Prefix:
First Name:JANTIRA
Middle Name:TARA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34476 SAINT MARON BLVD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-3219
Mailing Address - Country:US
Mailing Address - Phone:814-923-1324
Mailing Address - Fax:
Practice Address - Street 1:29000 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5293
Practice Address - Country:US
Practice Address - Phone:440-827-5784
Practice Address - Fax:440-827-5412
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-07
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34011590207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0127975Medicaid