Provider Demographics
NPI:1124166392
Name:ROE, THOMAS FRANKLIN (MD09)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:FRANKLIN
Last Name:ROE
Suffix:
Gender:M
Credentials:MD09
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 S CITRUS AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3038
Mailing Address - Country:US
Mailing Address - Phone:323-934-1691
Mailing Address - Fax:323-934-1691
Practice Address - Street 1:240 S CITRUS AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-3038
Practice Address - Country:US
Practice Address - Phone:323-934-1691
Practice Address - Fax:323-934-1691
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG8155174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4394219Medicaid
CAC46770Medicare UPIN
CAWG8155Medicare ID - Type Unspecified