Provider Demographics
NPI:1801897483
Name:CHODOSH, THOMAS BRENT (DO)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BRENT
Last Name:CHODOSH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3933 UP RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78408-3020
Mailing Address - Country:US
Mailing Address - Phone:361-882-1001
Mailing Address - Fax:361-882-1040
Practice Address - Street 1:3933 UP RIVER RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78408-3020
Practice Address - Country:US
Practice Address - Phone:361-882-1001
Practice Address - Fax:361-882-1040
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2007-07-11
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
TXD6394207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164153201Medicaid
TXD75116Medicare UPIN
TX164153201Medicaid