Provider Demographics
NPI:1740290881
Name:BURKS, TOMMY RAY (OD)
Entity type:Individual
Prefix:DR
First Name:TOMMY
Middle Name:RAY
Last Name:BURKS
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 1:1922 SHADY BROOK PLAZA
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-3989
Mailing Address - Country:US
Mailing Address - Phone:931-388-2061
Mailing Address - Fax:
Practice Address - Street 1:1922 SHADY BROOK PLAZA
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-3989
Practice Address - Country:US
Practice Address - Phone:931-388-2061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1062DT152W00000X
TNODT940152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4025729Medicaid
TN4025729Medicaid
T61297Medicare UPIN