Provider Demographics
NPI:1881699015
Name:THOMAS, KEN (MD)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:THOMAS
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 1:622 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5052
Mailing Address - Country:US
Mailing Address - Phone:337-527-2491
Mailing Address - Fax:337-528-2749
Practice Address - Street 1:622 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5052
Practice Address - Country:US
Practice Address - Phone:337-527-2491
Practice Address - Fax:337-528-2749
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200106207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1787159Medicaid
LAI36059Medicare UPIN
LA1787159Medicaid