Provider Demographics
NPI:1568436186
Name:THOMAS, STUART JACKSON (OD)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:JACKSON
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 1:1077 BAXTER ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3767
Mailing Address - Country:US
Mailing Address - Phone:706-549-7757
Mailing Address - Fax:706-549-4186
Practice Address - Street 1:1077 BAXTER ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3767
Practice Address - Country:US
Practice Address - Phone:706-549-7757
Practice Address - Fax:706-549-4186
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 1062152WS0006X
GAGA1062152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00314388AMedicaid
GA511I410042Medicare PIN
GA00314388AMedicaid