Healthcare Provider Details

I. General information

NPI: 1518958420
Provider Name (Legal Business Name): FRED NICHOLAS THOMAS III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 EXECUTIVE DR STE A
HAMPTON VA
23666-2948
US

IV. Provider business mailing address

860 OMNI BLVD STE 101
NEWPORT NEWS VA
23606-4430
US

V. Phone/Fax

Practice location:
  • Phone: 757-223-4992
  • Fax: 757-223-5350
Mailing address:
  • Phone: 757-232-8769
  • Fax: 757-232-8875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number0101238297
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101238297
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: