Provider Demographics
NPI:1730207754
Name:THOMAS, SHAWN DALE (LO)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:DALE
Last Name:THOMAS
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6812 E HIGHWAY 67
Mailing Address - Street 2:
Mailing Address - City:ALVARADO
Mailing Address - State:TX
Mailing Address - Zip Code:76009-6857
Mailing Address - Country:US
Mailing Address - Phone:817-783-2757
Mailing Address - Fax:866-591-2741
Practice Address - Street 1:6812 E HIGHWAY 67
Practice Address - Street 2:
Practice Address - City:ALVARADO
Practice Address - State:TX
Practice Address - Zip Code:76009-6857
Practice Address - Country:US
Practice Address - Phone:817-783-2757
Practice Address - Fax:866-591-2741
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX189222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189OtherORTHOTIC LICENSE