Provider Demographics
NPI:1124066436
Name:CONKLIN, THOMAS E (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:CONKLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2650 SANTA YNEZ AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2387
Mailing Address - Country:US
Mailing Address - Phone:818-701-0551
Mailing Address - Fax:818-701-5360
Practice Address - Street 1:18417 NORDHOFF ST
Practice Address - Street 2:SUITE# B
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-2200
Practice Address - Country:US
Practice Address - Phone:818-701-0551
Practice Address - Fax:818-701-5360
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA156153207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG44486OtherLICENSE NUMBER
CAG44486OtherLICENSE NUMBER