Provider Demographics
NPI:1144206749
Name:PRANIKOFF, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:PRANIKOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-6637
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-6637
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97011102086S0102X, 2086S0120X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ01110Medicaid
5510597OtherAETNA
NC891066MMedicaid
WV2005048000Medicaid
VA6724507Medicaid
17510OtherPARTNERS
74141OtherMEDCOST
1066MOtherBCBS
20051992OtherRR MEDICARE
NC891066MMedicaid
74141OtherMEDCOST