Provider Demographics
NPI:1801963194
Name:LAW, THOMAS BERNARD (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:BERNARD
Last Name:LAW
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 1:5763 JADEITE AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737
Mailing Address - Country:US
Mailing Address - Phone:909-935-5990
Mailing Address - Fax:
Practice Address - Street 1:190 WEST H STREET
Practice Address - Street 2:SUITE 105
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324
Practice Address - Country:US
Practice Address - Phone:909-825-9044
Practice Address - Fax:909-825-7392
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6488T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
522364679OtherFEDERAL TAX ID
CASD0064880Medicaid
CA47532460OtherSTATE TAX ID
U22933Medicare UPIN