Provider Demographics
NPI:1972605905
Name:ANTONIAN, THOMAS A (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:ANTONIAN
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 1:2728 PAWTUCKET AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914
Mailing Address - Country:US
Mailing Address - Phone:401-434-5532
Mailing Address - Fax:401-435-3405
Practice Address - Street 1:2728 PAWT AVE
Practice Address - Street 2:
Practice Address - City:EAST PROV
Practice Address - State:RI
Practice Address - Zip Code:02914
Practice Address - Country:US
Practice Address - Phone:401-434-5532
Practice Address - Fax:401-435-3405
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2550152W00000X
RIODTG00480152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9009886Medicaid
007010469Medicare ID - Type Unspecified
T53881Medicare UPIN