Provider Demographics
NPI:1013911403
Name:DETESCO, THOMAS NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:NICHOLAS
Last Name:DETESCO
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 1:7341 EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5900
Mailing Address - Country:US
Mailing Address - Phone:330-726-1138
Mailing Address - Fax:330-726-6128
Practice Address - Street 1:7341 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5900
Practice Address - Country:US
Practice Address - Phone:330-726-1138
Practice Address - Fax:330-726-6128
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35100173D207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35100173DOtherLICENSE
OH0359348Medicaid
OH0359348Medicaid
OHA75666Medicare UPIN
OHDE0425233Medicare ID - Type Unspecified