Basic Information
| Provider Information | |||||||||
| NPI: | 1508966805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DETERMAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DETERMAN | ||||||||
| OtherFirstName: | TOM | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2750 S PACIFIC AVE | ||||||||
| Address2: | STE D | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853653547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287827557 | ||||||||
| FaxNumber: | 9287838445 | ||||||||
| Practice Location | |||||||||
| Address1: | 2750 S PACIFIC AVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853653555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287827557 | ||||||||
| FaxNumber: | 9287838445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 01/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD 786 | AZ | Y | Eye and Vision Services Providers | Optometrist | 152WC0802X | OD 786 | AZ | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
ID Information
| ID | Type | State | Issuer | Description | 410030328 | 01 | AZ | RAILROAD | OTHER | AZ0249670 | 01 | AZ | BCBS ARIZONA | OTHER | 131533001 | 01 | AZ | DMERC | OTHER |