MEDICARE: THOMAS J CUOMO JR MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QG0300X	Geriatric Medicine (Family Medicine) Physician	21499	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0723220	OTHER	AZ	BCBS PROVIDER NUMBER
2	170723	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1205812757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS J CUOMO JR MD

Provider Business Mailing Address
First Line	:	11818 N 55TH PL
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85254-4790
Country	:	US
Telephone Number	:	602-859-9888
Fax Number	:	480-922-5903

Provider Business Practice Location Address
First Line	:	13835 N TATUM BLVD
Second Line	:	9615
City	:	PHOENIX
State	:	AZ
Zip	:	85032-5581
Country	:	US
Telephone Number	:	602-859-9888
Fax Number	:	480-922-5903

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	07/09/2007

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