Provider Demographics
NPI:1205973195
Name:REYBURN, THOMAS P (OD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:P
Last Name:REYBURN
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:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-0219
Mailing Address - Country:US
Mailing Address - Phone:616-676-1283
Mailing Address - Fax:616-676-9133
Practice Address - Street 1:400 ADA DR SE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8429
Practice Address - Country:US
Practice Address - Phone:616-676-1283
Practice Address - Fax:616-676-9133
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI94-4140369Medicaid
MI94-4140369Medicaid