Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1376696054 |
---|---|
Provider Name | Mr. Robert Thomas |
First Address | Germantown, TN 38138-3653 |
Second Address | Germantown, TN 38138-3653 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/01/2007 |
Last Update Date | 19/02/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0165655 | BLUE CROSS BLUE SHIELD (01) | TN |
3554760 | (05) | TN |