Provider Demographics
NPI:1770505562
Name:MOOMAW, THOMAS J (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:MOOMAW
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 1:1 MASSILLON MARKETPLACE DR SW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-2018
Mailing Address - Country:US
Mailing Address - Phone:330-730-4666
Mailing Address - Fax:
Practice Address - Street 1:1 MASSILLON MARKETPLACE DR SW
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-2018
Practice Address - Country:US
Practice Address - Phone:330-730-4666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3081152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0277865Medicaid
OH0277865Medicaid
OH0729890001Medicare NSC
OH0418231Medicare PIN