Provider Demographics
NPI:1407881477
Name:THOMAS, EVAN B (OD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:B
Last Name:THOMAS
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 1:522 OLD NEWPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663
Mailing Address - Country:US
Mailing Address - Phone:949-650-9060
Mailing Address - Fax:949-646-1461
Practice Address - Street 1:522 OLD NEWPORT BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663
Practice Address - Country:US
Practice Address - Phone:949-650-9060
Practice Address - Fax:949-646-1461
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4468152W00000X
CAOPT4468TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OP4468Medicare PIN
0279080001Medicare NSC
T69902Medicare UPIN