Provider Demographics
NPI:1831106996
Name:JUSTUS, THOMAS G (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:JUSTUS
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 1:1023 S MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104
Mailing Address - Country:US
Mailing Address - Phone:501-332-6262
Mailing Address - Fax:501-337-0373
Practice Address - Street 1:1023 S MAIN STREET
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104
Practice Address - Country:US
Practice Address - Phone:501-332-6262
Practice Address - Fax:501-337-0373
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2312152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0396990001OtherDME MAC JURISDICTION C
AR0396990001OtherDME MAC JURISDICTION C
AR49512Medicare ID - Type Unspecified