Provider Demographics
NPI:1861240335
Name:THOMAS, DOMINIQUE JAVON
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:JAVON
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10708 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-2606
Mailing Address - Country:US
Mailing Address - Phone:918-418-0217
Mailing Address - Fax:
Practice Address - Street 1:10708 E 41ST ST APT 211
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-2606
Practice Address - Country:US
Practice Address - Phone:918-418-0217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist