Provider Demographics
NPI:1396714135
Name:THOMAS, MARK KIERNAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:KIERNAN
Last Name:THOMAS
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 1:2700 SE STRATUS AVE UNIT 303
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6257
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 SE STRATUS AVE UNIT 303
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6257
Practice Address - Country:US
Practice Address - Phone:503-435-4520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD180256207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNTN0134OtherJOHN DEERE HEALTHCARE
TN100011285OtherTENNCARE
TNTN0184OtherJOHN DEERE HEALTHCARE
TN1315687OtherUNITED HEALTH CARE
TN3092413Medicaid
TN3071396OtherBLUE CROSS BLUE SHIELD
TN4496138OtherAETNA
TNP00259915OtherRAILROAD MEDICARE
TNP00259915OtherRAILROAD MEDICARE
TN3071396OtherBLUE CROSS BLUE SHIELD
TN3092413Medicaid
TNTN0134OtherJOHN DEERE HEALTHCARE
3092416Medicare ID - Type Unspecified