Provider Demographics
NPI:1669402327
Name:BIDDISON, THOMAS DEAN (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:DEAN
Last Name:BIDDISON
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 1:1625 SCHRADER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6213
Mailing Address - Country:US
Mailing Address - Phone:323-993-7500
Mailing Address - Fax:323-308-4015
Practice Address - Street 1:1625 SCHRADER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6213
Practice Address - Country:US
Practice Address - Phone:323-993-7500
Practice Address - Fax:323-308-4015
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55699207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A556990Medicaid
CAWA55699EMedicare ID - Type Unspecified
CAG87613Medicare UPIN