Provider Demographics
NPI:1285726307
Name:VADER, THOMAS B (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
Last Name:VADER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 129
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239
Mailing Address - Country:US
Mailing Address - Phone:360-678-4071
Mailing Address - Fax:360-678-6014
Practice Address - Street 1:101 N MAIN ST
Practice Address - Street 2:WHIDBEY GENERAL HOSPITAL
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239
Practice Address - Country:US
Practice Address - Phone:360-678-6018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015541207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA15522OtherREGENCE BLUE SHIELD
WA1124403Medicaid
WA0015292OtherDLI
WA15522OtherREGENCE BLUE SHIELD