Provider Demographics
NPI:1942269196
Name:MACEJKO, THOMAS T (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:T
Last Name:MACEJKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 FAIR LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-3434
Mailing Address - Country:US
Mailing Address - Phone:513-221-5274
Mailing Address - Fax:513-961-5100
Practice Address - Street 1:563 WESSEL DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-3668
Practice Address - Country:US
Practice Address - Phone:513-858-6500
Practice Address - Fax:513-858-2777
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-034971207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0261961Medicaid
OH180032055OtherRAILROAD MEDICARE
OH0872751Medicare PIN
OH180032055OtherRAILROAD MEDICARE
OH0872753Medicare PIN
OHE11512Medicare UPIN
OH0420948Medicare PIN
OH0420947Medicare PIN
OH0261961Medicaid