Provider Demographics
NPI:1447698220
Name:THOMAS, KYLE MATTHEW (DO)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MATTHEW
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:55 WHITCHER ST NE STE 130
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1156
Mailing Address - Country:US
Mailing Address - Phone:770-428-0462
Mailing Address - Fax:770-427-8001
Practice Address - Street 1:55 WHITCHER ST NE STE 130
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1156
Practice Address - Country:US
Practice Address - Phone:770-428-0462
Practice Address - Fax:770-427-8001
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010206432086S0102X
OH34.0140052086S0102X
GA863682086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0366962Medicaid