Provider Demographics
NPI:1386901809
Name:THOMAS, SAM
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:SAMUEL
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:820 PRUDENTIAL DR STE 304
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8205
Practice Address - Country:US
Practice Address - Phone:904-346-3649
Practice Address - Fax:904-348-5627
Is Sole Proprietor?:No
Enumeration Date:2012-04-22
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123547207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01514695OtherRAILROAD MEDICARE
FL014816100Medicaid
FLIF679YMedicare PIN