Provider Demographics
NPI:1912388968
Name:NEUBAUER, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:NEUBAUER
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 1:9300 DEWITT LOOP
Mailing Address - Street 2:SPORTS MEDICINE CLINIC
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060
Mailing Address - Country:US
Mailing Address - Phone:571-231-2195
Mailing Address - Fax:
Practice Address - Street 1:9300 DEWITT LOOP
Practice Address - Street 2:SPORTS MEDICINE CLINIC
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060
Practice Address - Country:US
Practice Address - Phone:571-231-2195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY285105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1912388968Medicaid