Basic Information
| Provider Information | |||||||||
| NPI: | 1396700803 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 N CENTRAL AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079331221 | ||||||||
| FaxNumber: | 4079330747 | ||||||||
| Practice Location | |||||||||
| Address1: | 1121 N CENTRAL AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079331221 | ||||||||
| FaxNumber: | 4079330747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 02/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 0056928 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 0056928 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 52669000 | 05 | FL | MEDICAID |