Provider Demographics
NPI:1740339464
Name:NETTER, THOMAS A (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:NETTER
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 1:230 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3176
Mailing Address - Country:US
Mailing Address - Phone:321-956-7530
Mailing Address - Fax:
Practice Address - Street 1:12196 COUNTY ROAD 512
Practice Address - Street 2:
Practice Address - City:FELLSMERE
Practice Address - State:FL
Practice Address - Zip Code:32948-5463
Practice Address - Country:US
Practice Address - Phone:772-257-8224
Practice Address - Fax:772-571-8846
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME33902208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD61233Medicare UPIN
FL05428Medicare ID - Type Unspecified