Provider Demographics
NPI:1437201076
Name:MISIEWICZ, THOMAS PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:PAUL
Last Name:MISIEWICZ
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:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06083-1289
Mailing Address - Country:US
Mailing Address - Phone:860-745-8055
Mailing Address - Fax:860-745-2355
Practice Address - Street 1:25 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-1289
Practice Address - Country:US
Practice Address - Phone:860-745-8055
Practice Address - Fax:860-745-2355
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000971152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0519191OtherAETNA
0596650001OtherMEDICARE MATERIALS
CT738255OtherCONNECTICARE
UPIN 27681OtherVISION SERVICE PLAN
TX0005971059OtherAETNA
UPIN 27681OtherCIGNA
CT09000971CT01OtherANTHEM BCBS
11220239OtherCAQH
0519191OtherAETNA