Basic Information
| Provider Information | |||||||||
| NPI: | 1619939212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603024091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084450898 | ||||||||
| FaxNumber: | 7084450907 | ||||||||
| Practice Location | |||||||||
| Address1: | 9718 S HALSTED ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606281007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732334100 | ||||||||
| FaxNumber: | 7732334055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 10/30/2015 | ||||||||
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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 | 207R00000X | 036078052 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036078052 | 05 | IL | MEDICAID |