Healthcare Provider Details

I. General information

NPI: 1306118328
Provider Name (Legal Business Name): JEFF THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13660 N 94TH DR STE D1
PEORIA AZ
85381-4836
US

IV. Provider business mailing address

13660 N 94TH DR STE F1
PEORIA AZ
85381-4232
US

V. Phone/Fax

Practice location:
  • Phone: 623-974-0522
  • Fax: 623-933-5787
Mailing address:
  • Phone: 623-974-0522
  • Fax: 623-933-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number41000243A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: