Basic Information
| Provider Information | |||||||||
| NPI: | 1376510529 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOM | ||||||||
| FirstName: | FREDERICK | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 CABALLEROS AVE | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934017908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055497930 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 877 OAK PARK BLVD. | ||||||||
| Address2: | MED PLUS MEDICAL CENTER | ||||||||
| City: | PISMO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054748450 | ||||||||
| FaxNumber: | 8054748454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 07/11/2008 | ||||||||
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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 | G61780 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 240629 | 01 | BLUE CROSS WORKERS COMP K | OTHER | DF2146 | 01 | RAILROAD MEDICARE GROUP | OTHER | 5255526 | 01 | PPNI | OTHER | 0217529 | 01 | WASHINGTON STATE DOL PROV | OTHER | 240630 | 01 | BLUE CROSS WORKERS COMP S | OTHER | G61780 | 01 | LICENSE | OTHER | 235229 | 01 | BLUE CROSS WORKERS COMP P | OTHER | P00347364 | 01 | RAILROAD MEDICARE PIN | OTHER |