Provider Demographics
NPI:1104067420
Name:TOM, DEEPA (MD)
Entity type:Individual
Prefix:
First Name:DEEPA
Middle Name:
Last Name:TOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1500
Mailing Address - Fax:909-398-1488
Practice Address - Street 1:1818 N. ORANGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3006
Practice Address - Country:US
Practice Address - Phone:909-630-7158
Practice Address - Fax:909-630-7983
Is Sole Proprietor?:No
Enumeration Date:2009-03-17
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106732207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1067320Medicaid
CACE610XMedicare PIN
CACE610WMedicare PIN
CACE610YMedicare PIN
CACE610VMedicare PIN
CACE610ZMedicare PIN