MEDICARE: THOMAS ROBERT DEJAK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	037190	GA

General Provider Information

NPI Number	:	1609060318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS ROBERT DEJAK M.D.

Provider Business Mailing Address
First Line	:	296 ROSWELL COMMONS CIR
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30076-1594
Country	:	US
Telephone Number	:	770-649-9880
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 PARK EAST DR
Second Line	:	4TH FLOOR
City	:	CLEVELAND
State	:	OH
Zip	:	44122-4339
Country	:	US
Telephone Number	:	216-763-3106
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2007
Last Update Date	:	09/05/2007

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