Provider Demographics
NPI:1780607853
Name:TOMCZAK, THOMAS E JR (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:TOMCZAK
Suffix:JR
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 1:401 S. BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1591
Practice Address - Street 1:2431 S. M-30
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-9312
Practice Address - Country:US
Practice Address - Phone:989-894-3278
Practice Address - Fax:989-891-8155
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704213286363LF0000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4891491Medicaid
MIN85240009Medicare PIN
MIP02220003Medicare PIN
MIQ29603Medicare UPIN