Provider Demographics
NPI:1285633693
Name:THOMAS, TINA RENEE (OD)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:RENEE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8921 N WOOD SAGE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7822
Mailing Address - Country:US
Mailing Address - Phone:309-243-3869
Mailing Address - Fax:309-243-7918
Practice Address - Street 1:8921 N WOOD SAGE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7822
Practice Address - Country:US
Practice Address - Phone:309-243-2400
Practice Address - Fax:309-243-7918
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008635Medicaid
IL09030205OtherBLUE CROSS BLUE SHIELD
ILK14087Medicare ID - Type Unspecified
IL046008635Medicaid
ILU54649Medicare UPIN
K30680Medicare ID - Type Unspecified