Provider Demographics
NPI:1063452639
Name:BLANKS, THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:BLANKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:BLANKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-865-1453
Mailing Address - Fax:228-865-1451
Practice Address - Street 1:1110 BROAD AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-8907
Practice Address - Country:US
Practice Address - Phone:228-864-0314
Practice Address - Fax:228-864-0425
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08702207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112507Medicaid
MSP00651241OtherRAILROAD MEDICARE
MS00112507Medicaid
MS$$$$$$$$$COtherBCBS
MS00112507Medicaid
MSP00651241OtherRAILROAD MEDICARE
MS302I115949Medicare PIN
MSB64784Medicare UPIN