Provider Demographics
NPI:1578539235
Name:CHURCH, THOMAS CARTON (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:CARTON
Last Name:CHURCH
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 1:51 YACHT CLUB DR NE
Mailing Address - Street 2:
Mailing Address - City:FT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4473
Mailing Address - Country:US
Mailing Address - Phone:850-244-1157
Mailing Address - Fax:
Practice Address - Street 1:51 YACHT CLUB DR NE
Practice Address - Street 2:
Practice Address - City:FT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-4473
Practice Address - Country:US
Practice Address - Phone:850-244-1157
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0016848207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD54931Medicare UPIN
FL46063Medicare ID - Type Unspecified