Provider Demographics
NPI:1992795090
Name:EAGAN, THOMAS STANFORD (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:STANFORD
Last Name:EAGAN
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 1:215 COUNTY HIGHWAY 128
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-4806
Mailing Address - Country:US
Mailing Address - Phone:518-773-7306
Mailing Address - Fax:518-773-8511
Practice Address - Street 1:215 COUNTY HIGHWAY 128
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-4806
Practice Address - Country:US
Practice Address - Phone:518-773-7306
Practice Address - Fax:518-773-8511
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1162791207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1162791OtherWC
NY00527239Medicaid
NY000420268001OtherBSNENY
NY54728BMedicare ID - Type Unspecified
NY000420268001OtherBSNENY