Provider Demographics
NPI:1083241228
Name:THOMAS, IAN STEPHON (MD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:STEPHON
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MASS AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 COLUMBIA AVE E
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49014-5159
Practice Address - Country:US
Practice Address - Phone:269-883-6052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.143499208D00000X
MA1015023207Q00000X
MI4301505818207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine