Healthcare Provider Details

I. General information

NPI: 1033478276
Provider Name (Legal Business Name): MATTHEW BRADY THOMAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 MONTGOMERY DR
SANTA ROSA CA
95405-4801
US

IV. Provider business mailing address

1165 MONTGOMERY DR
SANTA ROSA CA
95405-4801
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-3210
  • Fax:
Mailing address:
  • Phone: 707-546-3210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number072506
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA135498
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: