Healthcare Provider Details

I. General information

NPI: 1104835925
Provider Name (Legal Business Name): JOHN MICHAEL THOMASSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 E COMMERCIAL BLVD SUITE 103
FT LAUDERDALE FL
33308-4229
US

IV. Provider business mailing address

2800 E COMMERCIAL BLVD SUITE 103
FT LAUDERDALE FL
33308-4229
US

V. Phone/Fax

Practice location:
  • Phone: 954-771-0200
  • Fax: 954-208-5171
Mailing address:
  • Phone: 954-771-0200
  • Fax: 954-208-5171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME 95272
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD 33673
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0101231653
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: