Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 47171 | WI |
N | 207QA0401X | Family Doctor - Addiction Medicine | 47171 | WI |
N | 207QA0505X | Family Doctor - Adult Medicine | 47171 | WI |
NPI | 1790870558 |
---|---|
Provider Name | Dr. Manuel De Jesus Thomas |
First Address | Milwaukee, WI 53215-4617 |
Second Address | Milwaukee, WI 53215-4617 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2006 |
Last Update Date | 07/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
038.147540 | STATE OF IL (01) | IL |