Provider Demographics
NPI:1679539993
Name:THOMAS, MICHAEL WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:THOMAS
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 1:205 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-2239
Mailing Address - Country:US
Mailing Address - Phone:815-568-6508
Mailing Address - Fax:815-568-4896
Practice Address - Street 1:205 N STATE ST
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-2239
Practice Address - Country:US
Practice Address - Phone:815-568-6508
Practice Address - Fax:815-568-4896
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009334152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00049324111OtherBLUE CROSS BLUE SHIELD
IL046009334Medicaid
IL00049324111OtherBLUE CROSS BLUE SHIELD