Provider Demographics
NPI:1699872366
Name:THOMAS, BERT J (MD)
Entity type:Individual
Prefix:
First Name:BERT
Middle Name:J
Last Name:THOMAS
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 1:15332 ANTIOCH ST # 105
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3603
Mailing Address - Country:US
Mailing Address - Phone:310-202-6204
Mailing Address - Fax:310-202-0831
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-202-6204
Practice Address - Fax:310-202-0831
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43282207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G432820Medicaid
CAA49297Medicare UPIN
CAG43282Medicare ID - Type UnspecifiedMEDICARE PPIN #