Provider Demographics
NPI:1477550184
Name:DEHAVEN, THOMAS J (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:DEHAVEN
Suffix:
Gender:M
Credentials:MD
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:1424 EAST FRONT
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8501
Practice Address - Country:US
Practice Address - Phone:903-595-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0289207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX704849OtherMEDICARE
TXP02098855OtherMEDICARE RAIL ROAD
TX1299542OtherUNITED HEALTHCARE
TX4471007OtherAETNA
TX733072OtherFIRST HEALTH
TX89V970OtherBLUE CROSS BLUE SHIELD
TX129097506Medicaid
TX129097501Medicaid
TX2929696OtherCIGNA