Provider Demographics
NPI:1750519906
Name:NEELY, THOMAS R (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:NEELY
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 1:330 CLINTON ST
Mailing Address - Street 2:APT 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-3737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:165 SMITH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6337
Practice Address - Country:US
Practice Address - Phone:212-441-4380
Practice Address - Fax:212-876-4353
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251036207R00000X
MA241077390200000X
NY277686207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program