Provider Demographics
NPI:1649279076
Name:ROBERSON, THOMAS A (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3548 N MOUNT JULIET RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-3061
Mailing Address - Country:US
Mailing Address - Phone:615-754-4733
Mailing Address - Fax:615-758-7515
Practice Address - Street 1:3458 N MOUNT JULIET RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3011
Practice Address - Country:US
Practice Address - Phone:615-453-5155
Practice Address - Fax:615-444-5915
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT633152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN000017678OtherBCBS MEDICARE ADVANTAGE
TN3593913Medicaid
TN903833OtherBLOCK VISION
TN1238610001OtherDMERC
TN000017678OtherBLUE CROSS BLUE SHIELD TN
TN000017678OtherTENNCARE SELECT
TN410045577OtherPALMETTO-GBA
TN4406651OtherAETNA US HEALTHCARE
TN621298175OtherDEFAULT
TN903833OtherBLOCK VISION