Healthcare Provider Details

I. General information

NPI: 1659370039
Provider Name (Legal Business Name): MICHELLE DENISE THOMAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12172 CENTRAL AVE #100
MITCHELLVILLE MD
20721-1900
US

IV. Provider business mailing address

PO BOX 15609
WASHINGTON DC
20003-0609
US

V. Phone/Fax

Practice location:
  • Phone: 307-390-5704
  • Fax: 301-464-7921
Mailing address:
  • Phone: 301-390-5704
  • Fax: 301-464-7921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberD41401
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101056850
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD19906
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number073406
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberD41401
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: