1649279076 NPI number — THOMAS A ROBERSON O.D.

Table of content: THOMAS A ROBERSON O.D. (NPI 1649279076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649279076 NPI number — THOMAS A ROBERSON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERSON
Provider First Name:
THOMAS
Provider Middle Name:
A
Provider Name Prefix Text:
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:
1649279076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3548 N MOUNT JULIET RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT JULIET
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37122-3061
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-754-4733
Provider Business Mailing Address Fax Number:
615-758-7515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3458 N MOUNT JULIET RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT JULIET
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37122-3011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-453-5155
Provider Business Practice Location Address Fax Number:
615-444-5915
Provider Enumeration Date:
07/18/2005

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:  ODT633 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000017678 . This is a "BCBS MEDICARE ADVANTAGE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3593913 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 903833 . This is a "BLOCK VISION" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1238610001 . This is a "DMERC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000017678 . This is a "BLUE CROSS BLUE SHIELD TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000017678 . This is a "TENNCARE SELECT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 410045577 . This is a "PALMETTO-GBA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4406651 . This is a "AETNA US HEALTHCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 621298175 . This is a "DEFAULT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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