Healthcare Provider Details

I. General information

NPI: 1447476312
Provider Name (Legal Business Name): SEAN R THOMAS MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55585 29 PALMS HWY
YUCCA VALLEY CA
92284-2505
US

IV. Provider business mailing address

55585 29 PALMS HWY
YUCCA VALLEY CA
92284-2505
US

V. Phone/Fax

Practice location:
  • Phone: 760-228-3366
  • Fax: 760-228-3369
Mailing address:
  • Phone: 760-228-3366
  • Fax: 760-228-3369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA60305
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA60305
License Number StateCA

VIII. Authorized Official

Name: MS. JANUARIE BAUTISA
Title or Position: CONTRACTS DIRECTOR
Credential:
Phone: 760-228-3366