Provider Demographics
NPI:1104902600
Name:THOMAS, LIZY BOSE (MD)
Entity type:Individual
Prefix:
First Name:LIZY
Middle Name:BOSE
Last Name:THOMAS
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 1:14999 HEALTH CENTER DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1074
Mailing Address - Country:US
Mailing Address - Phone:301-262-8188
Mailing Address - Fax:301-464-8233
Practice Address - Street 1:14999 HEALTH CENTER DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1074
Practice Address - Country:US
Practice Address - Phone:301-262-8188
Practice Address - Fax:301-464-8233
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD31662207R00000X
MDD0055376207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC026714900Medicaid
DC026714900Medicaid
DCH68509Medicare UPIN