Provider Demographics
NPI:1023046158
Name:FAIRLEY, THOMAS R (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:FAIRLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 SUMMA AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3726
Mailing Address - Country:US
Mailing Address - Phone:225-761-5200
Mailing Address - Fax:
Practice Address - Street 1:9001 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3726
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:225-761-5618
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1220-389T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1693308Medicaid
LA1693308Medicaid
4B225Medicare ID - Type Unspecified