Provider Demographics
NPI:1972375996
Name:RAJU THOMAS, TIBU
Entity Type:Individual
Prefix:MR
First Name:TIBU
Middle Name:
Last Name:RAJU THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-2509
Mailing Address - Country:US
Mailing Address - Phone:201-289-3763
Mailing Address - Fax:
Practice Address - Street 1:177 FT WASHINGTN AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:332-218-4002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR16978900163WM0705X
NJ26NJ14954700363LA2200X
NY675168163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health