=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306825500
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS WALDON STATON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2006
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28 CHICK ST STE 100
-----------------------------------------------------
City | METROPOLIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62960-2467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-524-8381
-----------------------------------------------------
Fax | 618-638-1316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 CHICK ST STE 100
-----------------------------------------------------
City | METROPOLIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62960-2467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-524-8381
-----------------------------------------------------
Fax | 618-638-1316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036086549
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------