Basic Information
| Provider Information | |||||||||
| NPI: | 1033169891 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACLENNAN | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930620190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593100287 | ||||||||
| FaxNumber: | 8055226401 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 W PUTNAM AVE | ||||||||
| Address2: | |||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932573320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593100287 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G23748 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G237480 | 05 | CA | MEDICAID |