Healthcare Provider Details

I. General information

NPI: 1992929376
Provider Name (Legal Business Name): M. CALHOUN THOMAS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 PARK AVENUE
ORANGE NJ
07050
US

IV. Provider business mailing address

485 PARK AVENUE
ORANGE NJ
07050
US

V. Phone/Fax

Practice location:
  • Phone: 973-672-2770
  • Fax: 973-672-7009
Mailing address:
  • Phone: 973-672-2770
  • Fax: 973-672-7009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA035250
License Number StateNJ

VIII. Authorized Official

Name: DR. MONTRAE CALHOUN THOMAS
Title or Position: PHYSICIAN
Credential: MD
Phone: 973-672-2770