Provider Demographics
NPI:1164520896
Name:KRETZMER, THOMAS M (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
Last Name:KRETZMER
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 1:406 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286
Mailing Address - Country:US
Mailing Address - Phone:706-647-6608
Mailing Address - Fax:706-647-9207
Practice Address - Street 1:406 W MAIN ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286
Practice Address - Country:US
Practice Address - Phone:706-647-6608
Practice Address - Fax:706-647-9207
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA001241152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000446773CMedicaid
U11342Medicare UPIN
GA41ZCBPXMedicare PIN