MEDICARE: DR. MANUEL DE JESUS THOMAS 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	207QA0401X	Addiction Medicine (Family Medicine) Physician	47171	WI
2	207QA0505X	Adult Medicine Physician	47171	WI
3	207Q00000X	Family Medicine Physician	47171	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	038.147540	OTHER	IL	STATE OF IL

General Provider Information

NPI Number	:	1790870558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MANUEL DE JESUS THOMAS MD

Provider Business Mailing Address
First Line	:	1107 W OKLAHOMA AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-4617
Country	:	US
Telephone Number	:	414-463-2607
Fax Number	:

Provider Business Practice Location Address
First Line	:	1107 W OKLAHOMA AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-4617
Country	:	US
Telephone Number	:	414-463-2607
Fax Number	:

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

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	03/07/2019

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