Basic Information
| Provider Information | |||||||||
| NPI: | 1316076698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORTESE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639010 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 4020 W GOELLER BLVD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472018273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126690141 | ||||||||
| FaxNumber: | 8882540293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 03/06/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 01020422A | IN | Y | Allopathic & Osteopathic Physicians | Dermatology | 207NS0135X | 01020422A | IN | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
No ID Information.