Provider Demographics
NPI:1861597593
Name:THOMAS, MITCHELL (PT)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 MAMARONECK AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-5224
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:
Practice Address - Street 1:301 S RIDGE AVE UNIT 301-303
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-4650
Practice Address - Country:US
Practice Address - Phone:302-888-9480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21363225100000X
DEJ10001570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
62243004OtherCAREFIRST
DEJ10001570OtherDE LICENSE
1861597593OtherTRICARE CHAMPUS
5070-0082OtherNCA
2859738000OtherAMERIHEALTH IBC
11779633OtherCAQH
2859738000OtherAMERIHEALTH IBC
MD306PR253Medicare PIN
1861597593OtherTRICARE CHAMPUS