Provider Demographics
NPI:1811160237
Name:DAVID R. TOMAZIC, D.O., LLC
Entity type:Organization
Organization Name:DAVID R. TOMAZIC, D.O., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:TOMAZIC
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:570-785-5599
Mailing Address - Street 1:632 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:PA
Mailing Address - Zip Code:18421-1483
Mailing Address - Country:US
Mailing Address - Phone:570-785-5599
Mailing Address - Fax:570-785-3552
Practice Address - Street 1:632 MAIN ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:PA
Practice Address - Zip Code:18421-1483
Practice Address - Country:US
Practice Address - Phone:570-785-5599
Practice Address - Fax:570-785-3552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004178L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102107900001Medicaid
PA040568OtherPA BLUE SHIELD
080001919OtherRAILROAD MEDICARE
PA040568OtherPA BLUE SHIELD