Provider Demographics
NPI:1649282542
Name:THOMASON, ISAAC RAYMOND (MD)
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:RAYMOND
Last Name:THOMASON
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:PO BOX 413033
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3033
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:801-581-7476
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-6795
Practice Address - Fax:801-581-7476
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT161210-1205207R00000X, 207RG0100X, 207RT0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT100007589OtherRR MEDICARE PIN
UTE00023Medicare UPIN
UT005532202Medicare PIN