Provider Demographics
NPI:1376750380
Name:TESSMER, THOMAS J (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:TESSMER
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14455 W GRAND AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7194
Mailing Address - Country:US
Mailing Address - Phone:623-546-2080
Mailing Address - Fax:623-546-3915
Practice Address - Street 1:14455 W GRAND AVE
Practice Address - Street 2:STE 102
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7196
Practice Address - Country:US
Practice Address - Phone:623-546-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1268160001Medicare NSC