Provider Demographics
NPI:1063284479
Name:THOMAS, IDRIS JAMAL
Entity type:Individual
Prefix:
First Name:IDRIS
Middle Name:JAMAL
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 E JAMES ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-5005
Mailing Address - Country:US
Mailing Address - Phone:317-201-4249
Mailing Address - Fax:
Practice Address - Street 1:803 E JAMES ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-5005
Practice Address - Country:US
Practice Address - Phone:317-201-4249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA102982225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist