Provider Demographics
NPI:1790788149
Name:GULIBON, THOMAS M JR (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:GULIBON
Suffix:JR
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 1:720 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-3844
Mailing Address - Country:US
Mailing Address - Phone:610-933-3498
Mailing Address - Fax:610-933-5052
Practice Address - Street 1:720 MAIN ST
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-3844
Practice Address - Country:US
Practice Address - Phone:610-933-3498
Practice Address - Fax:610-933-5052
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000234152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU61863Medicare UPIN
PAGU879152Medicare ID - Type Unspecified