Provider Demographics
NPI:1346318235
Name:SHOEMAKER, THOMAS J (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:SHOEMAKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:SHIMUL
Other - Middle Name:Y
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:122 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1106
Mailing Address - Country:US
Mailing Address - Phone:934-642-1300
Mailing Address - Fax:937-642-0101
Practice Address - Street 1:122 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1106
Practice Address - Country:US
Practice Address - Phone:934-642-1300
Practice Address - Fax:937-642-0101
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5156152W00000X
OHOH5091152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH410046890OtherRAILROAD MEDICARE
OH2202585OtherUNITED HEALTH CARE
OH2262144Medicaid
OH000000218755OtherANTHEM BXBS
OH2557352OtherAETNA
OH2557352OtherAETNA
OH2557352OtherAETNA
OHSP01791Medicare PIN
OH4221150001Medicare NSC
OH$$$$$$$$$001OtherMEDICAL MUTUAL