Provider Demographics
NPI:1194257089
Name:FOSS, THOMAS FOTAKIS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:FOTAKIS
Last Name:FOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:THOMAS
Other - Last Name:FOTAKIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 S COUNTRY CLUB DR STE 3
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-5162
Mailing Address - Country:US
Mailing Address - Phone:480-827-5500
Mailing Address - Fax:
Practice Address - Street 1:1300 S COUNTRY CLUB DR STE 3
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5162
Practice Address - Country:US
Practice Address - Phone:480-827-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ60354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine