Basic Information
| Provider Information | |||||||||
| NPI: | 1184867814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHONEY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165640521 | ||||||||
| FaxNumber: | 8778602907 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 SUNRISE BLVD | ||||||||
| Address2: | SUITE 2500 | ||||||||
| City: | CITRUS HEIGHTS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956102300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167222227 | ||||||||
| FaxNumber: | 8778605422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2009 | ||||||||
| LastUpdateDate: | 03/28/2016 | ||||||||
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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 | 207Q00000X | A54815 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01463667-EFF3/18/15 | 01 | CA | RAILROAD MEDICARE-DV5277 | OTHER | EFFECTIVE- 1/22/2015 | 05 | CA | MEDICAID |