Provider Demographics
NPI:1699751321
Name:O'CALLAGHAN, THOMAS (MD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:O'CALLAGHAN
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:FILE NUMBER 54701
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:909-558-3111
Mailing Address - Fax:
Practice Address - Street 1:11370 ANDERSON ST
Practice Address - Street 2:STE. 2100
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42550208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C425500Medicaid
CA00C425500Medicaid
CA00C425501Medicare PIN