Provider Demographics
NPI:1962123471
Name:THOMAS, JOHN KEVIN (SPECIALIST)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KEVIN
Last Name:THOMAS
Suffix:
Gender:M
Credentials:SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15620 S NORMANDIE AVE APT J
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4041
Mailing Address - Country:US
Mailing Address - Phone:562-416-1656
Mailing Address - Fax:
Practice Address - Street 1:61 LAKEWOOD CENTER MALL STE J
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-2417
Practice Address - Country:US
Practice Address - Phone:562-416-1656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB782531744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management