Provider Demographics
NPI:1700811858
Name:DOOHAN, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:DOOHAN
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 1:413 RUNNING HORSE LN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7232
Mailing Address - Country:US
Mailing Address - Phone:704-999-0275
Mailing Address - Fax:
Practice Address - Street 1:413 RUNNING HORSE LN
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-7232
Practice Address - Country:US
Practice Address - Phone:704-999-0275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00826207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPENDINGOtherBCBS PROVIDER NUMBER
NCPENDINGMedicaid
NCPENDINGMedicaid