Provider Demographics
NPI:1396790689
Name:TOLMAN, JUSTIN MARC (OD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MARC
Last Name:TOLMAN
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 1:200 W RIO BONITO RD
Mailing Address - Street 2:
Mailing Address - City:BIGGS
Mailing Address - State:CA
Mailing Address - Zip Code:95917
Mailing Address - Country:US
Mailing Address - Phone:530-868-5065
Mailing Address - Fax:
Practice Address - Street 1:1245 THARP RD
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95993
Practice Address - Country:US
Practice Address - Phone:530-674-5273
Practice Address - Fax:530-674-5275
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12712T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0127120Medicaid
CASD0127120Medicare PIN
V04006Medicare UPIN
CAZZZ23333ZMedicare PIN