Healthcare Provider Details

I. General information

NPI: 1144715483
Provider Name (Legal Business Name): MARWA TARANISSI THOMAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR
COLUMBIA MO
65212-1000
US

IV. Provider business mailing address

1 HOSPITAL DR
COLUMBIA MO
65212-1000
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-1606
  • Fax: 573-884-4533
Mailing address:
  • Phone: 573-884-1606
  • Fax: 573-884-4533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2019016709
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: