1952660359 NPI number — JANTIRA TARA THOMAS D.O.

Table of content: JANTIRA TARA THOMAS D.O. (NPI 1952660359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952660359 NPI number — JANTIRA TARA THOMAS D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMAS
Provider First Name:
JANTIRA
Provider Middle Name:
TARA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

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:
1952660359
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34476 SAINT MARON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AVON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44011-3219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-923-1324
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29000 CENTER RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTLAKE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44145-5293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-827-5784
Provider Business Practice Location Address Fax Number:
440-827-5412
Provider Enumeration Date:
05/07/2012

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: 207R00000X , with the licence number:  34011590 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0127975 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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