Provider Demographics
NPI:1770837007
Name:THOMAS J. HAVILAND, OD, PC
Entity Type:Organization
Organization Name:THOMAS J. HAVILAND, OD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:HAVILAND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:864-579-2015
Mailing Address - Street 1:813 MONTCLAIR CT.
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-5348
Mailing Address - Country:US
Mailing Address - Phone:864-579-2015
Mailing Address - Fax:
Practice Address - Street 1:2151 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1441
Practice Address - Country:US
Practice Address - Phone:864-579-2015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-08
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC775152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD07758Medicaid