Basic Information
Provider Information | |||||||||
NPI: | 1912972787 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOMAS | ||||||||
FirstName: | SHERIDA | ||||||||
MiddleName: | LESLIE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8926 WOODYARD RD | ||||||||
Address2: | STE 301 | ||||||||
City: | CLINTON | ||||||||
State: | MD | ||||||||
PostalCode: | 207354220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018563670 | ||||||||
FaxNumber: | 3018560129 | ||||||||
Practice Location | |||||||||
Address1: | 7801 OLD BRANCH AVE | ||||||||
Address2: | STE 300 | ||||||||
City: | CLINTON | ||||||||
State: | MD | ||||||||
PostalCode: | 207351608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3018566718 | ||||||||
FaxNumber: | 3018566722 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/23/2006 | ||||||||
LastUpdateDate: | 03/13/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | D0034670 | MD | Y |   | Other Service Providers | Specialist |   | 174400000X | 0101040481 | VA | N |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 1912972787 | 05 | VA |   | MEDICAID | 809940501 | 05 | MD |   | MEDICAID |