Provider Demographics
NPI:1679538284
Name:MIRABILE, THOMAS JOSEPH (OD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:MIRABILE
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 1:1031 HIGHWAY 41
Mailing Address - Street 2:STE 400
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-9320
Mailing Address - Country:US
Mailing Address - Phone:843-388-1888
Mailing Address - Fax:843-856-9643
Practice Address - Street 1:1031 HIGHWAY 41
Practice Address - Street 2:STE 400
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-9320
Practice Address - Country:US
Practice Address - Phone:843-388-1888
Practice Address - Fax:843-856-9643
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1350152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD13509Medicaid
SCD13509Medicaid