Provider Demographics
NPI:1336185495
Name:PICCIRILLI, THOMAS ROBERT (OD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ROBERT
Last Name:PICCIRILLI
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 1:1831 LYCOMING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1523
Mailing Address - Country:US
Mailing Address - Phone:570-323-1111
Mailing Address - Fax:570-323-8805
Practice Address - Street 1:1831 LYCOMING CREEK RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1523
Practice Address - Country:US
Practice Address - Phone:570-323-1111
Practice Address - Fax:570-323-8805
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001386152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018520230001Medicaid
PA0018520230001Medicaid