Provider Demographics
NPI:1376696054
Name:THOMAS, ROBERT (BCO)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 KIRBY PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3653
Mailing Address - Country:US
Mailing Address - Phone:901-753-4724
Mailing Address - Fax:901-759-5920
Practice Address - Street 1:1900 KIRBY PKWY STE 102
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3653
Practice Address - Country:US
Practice Address - Phone:901-753-4724
Practice Address - Fax:901-759-5920
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3554760Medicaid
TN0165655OtherBLUE CROSS BLUE SHIELD
TN3554760Medicaid