Provider Demographics
NPI:1669401139
Name:MAHAFFEY, THOMAS L (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:MAHAFFEY
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 1:1107 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2544
Mailing Address - Country:US
Mailing Address - Phone:309-353-6660
Mailing Address - Fax:309-353-7664
Practice Address - Street 1:1107 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2544
Practice Address - Country:US
Practice Address - Phone:309-662-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008812152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008812Medicaid
ILU57876Medicare UPIN