Provider Demographics
NPI:1194703827
Name:DEWALD, THOMAS E (DC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:DEWALD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 W AVENUE N STE 101
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-2002
Mailing Address - Country:US
Mailing Address - Phone:661-266-3500
Mailing Address - Fax:661-266-3591
Practice Address - Street 1:1037 W AVENUE N
Practice Address - Street 2:SUITE 101
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93551-2002
Practice Address - Country:US
Practice Address - Phone:661-266-3500
Practice Address - Fax:661-266-3591
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC021669111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC021669Medicaid
CAU41763Medicare UPIN