=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386831659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERWIN DALE THOMAS D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 07/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3726 JUNCTION BLVD
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11368-1741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-278-6377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 RIVERSIDE DR APT 1D
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10024-3727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-278-6377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 292444
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------