Provider Demographics
NPI:1427055672
Name:FEDERICI, THOMAS JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:FEDERICI
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 1:13 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2103
Mailing Address - Country:US
Mailing Address - Phone:518-218-1234
Mailing Address - Fax:518-218-1237
Practice Address - Street 1:223 GREAT OAKS BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5969
Practice Address - Country:US
Practice Address - Phone:518-218-1234
Practice Address - Fax:518-218-1237
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221767207W00000X, 207W00000X
SCMD29337207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1620483Medicaid
NY03053101Medicaid
SC293373Medicaid
SCI076292326Medicare PIN
I07629Medicare UPIN
SC293373Medicaid