1922050723 NPI number — DR. JOHN THOMAS THIEL MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922050723 NPI number — DR. JOHN THOMAS THIEL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THIEL
Provider First Name:
JOHN
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922050723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 9TH STREET
Provider Second Line Business Mailing Address:
ROOM 205 MAILSTOP 2 3
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95814-6414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-654-2431
Provider Business Mailing Address Fax Number:
916-654-3186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3102 EAST HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PATTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-425-7000
Provider Business Practice Location Address Fax Number:
909-425-7520
Provider Enumeration Date:
05/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  631588 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)