Provider Demographics
NPI:1811091044
Name:MESDAG, THOMAS T (DPM)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:T
Last Name:MESDAG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361
Mailing Address - Country:US
Mailing Address - Phone:503-838-3668
Mailing Address - Fax:503-606-2944
Practice Address - Street 1:343 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:OR
Practice Address - Zip Code:97361
Practice Address - Country:US
Practice Address - Phone:503-838-3668
Practice Address - Fax:503-606-2944
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROP00145213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR268177Medicaid
OR0000SGBGFMedicare ID - Type Unspecified
OR268177Medicaid