Basic Information
| Provider Information | |||||||||
| NPI: | 1487685988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2305 30TH. AVENUE | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625972020 | ||||||||
| FaxNumber: | 2625975452 | ||||||||
| Practice Location | |||||||||
| Address1: | 2305 30TH AVE | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531441411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625972020 | ||||||||
| FaxNumber: | 2625975452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/06/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | WI2152 | WI | Y | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
No ID Information.