Provider Demographics
NPI:1417934951
Name:CROFFEAD, THOMAS GEORGE (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:GEORGE
Last Name:CROFFEAD
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 1:3531 MARY ADER AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5896
Mailing Address - Country:US
Mailing Address - Phone:843-577-2047
Mailing Address - Fax:843-577-0640
Practice Address - Street 1:3531 MARY ADER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5896
Practice Address - Country:US
Practice Address - Phone:843-577-2047
Practice Address - Fax:843-577-0640
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC515152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD05153Medicaid
SC406580115OtherRAILROAD MEDICARE ID
SCDA9789OtherMEDICAID GROUP NUMBER
SCT24377Medicare UPIN
SCT243771767Medicare PIN