Provider Demographics
NPI:1497715619
Name:THOMAS, CHARLES (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
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 1:420 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422-2420
Mailing Address - Country:US
Mailing Address - Phone:985-748-8750
Mailing Address - Fax:985-748-8795
Practice Address - Street 1:420 N 2ND ST
Practice Address - Street 2:
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422-2420
Practice Address - Country:US
Practice Address - Phone:985-748-8750
Practice Address - Fax:985-748-8795
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA977254T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1351032Medicaid
LA1351032Medicaid
LA47918Medicare ID - Type Unspecified
LA5DM53Medicare UPIN