Provider Demographics
NPI:1386869147
Name:SEAN R THOMAS MD, INC
Entity type:Organization
Organization Name:SEAN R THOMAS MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTS DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANUARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:760-228-3366
Mailing Address - Street 1:55585 29 PALMS HWY
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-2505
Mailing Address - Country:US
Mailing Address - Phone:760-228-3366
Mailing Address - Fax:760-228-3369
Practice Address - Street 1:55585 29 PALMS HWY
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-2505
Practice Address - Country:US
Practice Address - Phone:760-228-3366
Practice Address - Fax:760-228-3369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
CAA603050261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53886GMedicaid
CA553886Medicare PIN