Provider Demographics
NPI:1568401107
Name:DUNHAM, THOMAS B (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
Last Name:DUNHAM
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 102635
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2635
Mailing Address - Country:US
Mailing Address - Phone:912-354-4800
Mailing Address - Fax:912-629-5821
Practice Address - Street 1:109 S DUVAL ST
Practice Address - Street 2:
Practice Address - City:CLAXTON
Practice Address - State:GA
Practice Address - Zip Code:30417-2029
Practice Address - Country:US
Practice Address - Phone:912-739-4031
Practice Address - Fax:912-739-0373
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001527152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00707858AMedicaid
678056OtherBLUE CROSS BLUE SHIELD
GA511G701032OtherGA MEDICARE GROUP
SCDD0527Medicaid
GA000707858FOtherMEDICAID - STATESBORO
GA000707858COtherMEDICAID - STATESBORO
GA1568401107OtherMEDICARE RAILROAD
SCDAG976OtherMEDICAID GRP. SAV.
GA000707858EOtherMEDICAID- CLAXTON
GA000707858EOtherMEDICAID- CLAXTON
GA1568401107OtherMEDICARE RAILROAD
GA0412940005Medicare NSC
GA6150410005Medicare NSC
GA410037102Medicare PIN
GA511G701032OtherGA MEDICARE GROUP
SCDAG976OtherMEDICAID GRP. SAV.
GA0412940007Medicare NSC
678056OtherBLUE CROSS BLUE SHIELD
GA0412940002Medicare NSC
SCDD0527Medicaid