Provider Demographics
NPI:1578556239
Name:MARSH, THOMAS K (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:K
Last Name:MARSH
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 1:1280 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4445
Mailing Address - Country:US
Mailing Address - Phone:262-567-3214
Mailing Address - Fax:262-567-2449
Practice Address - Street 1:1280 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4445
Practice Address - Country:US
Practice Address - Phone:262-567-3214
Practice Address - Fax:262-567-2449
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1507152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38564400Medicaid
WI38564400Medicaid
WI000147145Medicare ID - Type Unspecified
WI0414490001Medicare NSC