Provider Demographics
NPI:1801931647
Name:TOM, DAN G (OD)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:G
Last Name:TOM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:DAN
Other - Middle Name:G
Other - Last Name:TOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1520 W BAY AREA BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-2600
Mailing Address - Country:US
Mailing Address - Phone:832-934-1166
Mailing Address - Fax:832-934-1161
Practice Address - Street 1:1520 W BAY AREA BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-2600
Practice Address - Country:US
Practice Address - Phone:832-934-1166
Practice Address - Fax:832-934-1161
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3230TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093614803Medicaid
TX3230TGOtherTEXAS OPTOMETRY LICENSE
TXTXB137900Medicare PIN