Provider Demographics
NPI:1306956891
Name:WILEY, THOMAS MARVIN (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:MARVIN
Last Name:WILEY
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 1:1333 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864
Mailing Address - Country:US
Mailing Address - Phone:208-265-4140
Mailing Address - Fax:208-265-4448
Practice Address - Street 1:1333 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864
Practice Address - Country:US
Practice Address - Phone:208-265-4140
Practice Address - Fax:208-265-4448
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP602152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T76545Medicare UPIN