Healthcare Provider Details

I. General information

NPI: 1386715639
Provider Name (Legal Business Name): THOMAS BRENT WARREN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 GATEWAY BLVD
MOORESVILLE NC
28117-8522
US

IV. Provider business mailing address

140 GATEWAY BLVD
MOORESVILLE NC
28117-7561
US

V. Phone/Fax

Practice location:
  • Phone: 704-664-9638
  • Fax: 704-664-1859
Mailing address:
  • Phone: 704-664-9638
  • Fax: 704-664-1859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number200000659
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: