Provider Demographics
NPI:1346664745
Name:THOMAS, PHILLIP
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 HILLSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-1007
Mailing Address - Country:US
Mailing Address - Phone:502-548-2163
Mailing Address - Fax:812-565-2801
Practice Address - Street 1:102 HILLSIDE CIR
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-1007
Practice Address - Country:US
Practice Address - Phone:502-548-2163
Practice Address - Fax:812-565-2801
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1358156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician