Provider Demographics
NPI:1952607426
Name:ELIAS, THOMAS K (CO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:K
Last Name:ELIAS
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 N CHRISMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-9314
Mailing Address - Country:US
Mailing Address - Phone:800-726-9180
Mailing Address - Fax:800-866-5950
Practice Address - Street 1:2120 FOREST AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1478
Practice Address - Country:US
Practice Address - Phone:408-217-9387
Practice Address - Fax:408-866-4045
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246Z00000X
CACO002151222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXA0021510Medicaid