Provider Demographics
NPI:1215975719
Name:CEBALLOS, THOMAS K (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:K
Last Name:CEBALLOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:70 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-335-6671
Mailing Address - Fax:573-339-0083
Practice Address - Street 1:70 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4928
Practice Address - Country:US
Practice Address - Phone:573-335-6671
Practice Address - Fax:573-339-0083
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI741242085R0202X
FLME 929812085R0202X
MO20240417182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00433654OtherRR MEDICARE
FL276494600Medicaid
FL53766OtherFLORIDA BLUE CROSS BLUE SHIELD
FLAB768YMedicare PIN
FL53766OtherFLORIDA BLUE CROSS BLUE SHIELD
FLP00433654OtherRR MEDICARE
FL276494600Medicaid