Provider Demographics
NPI:1396820858
Name:BALDA, THOMAS J (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:BALDA
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 1:950 W MAIN ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047
Mailing Address - Country:US
Mailing Address - Phone:847-726-2020
Mailing Address - Fax:847-726-2036
Practice Address - Street 1:950 W MAIN ST
Practice Address - Street 2:SUITE 125
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047
Practice Address - Country:US
Practice Address - Phone:847-726-2020
Practice Address - Fax:847-726-2036
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008673152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008673Medicaid
U45708Medicare UPIN
IL046008673Medicaid