1336178672 NPI number — DR. THOMAS G VANZANDT O.D.

Table of content: DR. THOMAS G VANZANDT O.D. (NPI 1336178672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336178672 NPI number — DR. THOMAS G VANZANDT O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANZANDT
Provider First Name:
THOMAS
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336178672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
540 MEDICAL OAKS AVE STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33511-5995
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-684-2211
Provider Business Mailing Address Fax Number:
813-685-0895

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 MEDICAL OAKS AVE STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33511-5995
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-684-2211
Provider Business Practice Location Address Fax Number:
813-685-0895
Provider Enumeration Date:
06/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC2135 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 261659900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".