Provider Demographics
NPI:1053025148
Name:DODD, THOMAS JASON (MED, LAT, ATC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JASON
Last Name:DODD
Suffix:
Gender:M
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:VAN
Mailing Address - State:TX
Mailing Address - Zip Code:75790-3507
Mailing Address - Country:US
Mailing Address - Phone:903-275-7142
Mailing Address - Fax:
Practice Address - Street 1:259 COLORADO ST
Practice Address - Street 2:
Practice Address - City:VAN
Practice Address - State:TX
Practice Address - Zip Code:75790-3507
Practice Address - Country:US
Practice Address - Phone:903-275-7142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT61682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty