Basic Information
| Provider Information | |||||||||
| NPI: | 1477550184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEHAVEN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1424 EAST FRONT | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035954144 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | H0289 | TX | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 704849 | 01 | TX | MEDICARE | OTHER | P02098855 | 01 | TX | MEDICARE RAIL ROAD | OTHER | 1299542 | 01 | TX | UNITED HEALTHCARE | OTHER | 4471007 | 01 | TX | AETNA | OTHER | 733072 | 01 | TX | FIRST HEALTH | OTHER | 89V970 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 129097506 | 05 | TX | MEDICAID | 129097501 | 05 | TX | MEDICAID | 2929696 | 01 | TX | CIGNA | OTHER |