Basic Information
| Provider Information | |||||||||
| NPI: | 1770837007 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THOMAS J. HAVILAND, OD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 813 MONTCLAIR CT. | ||||||||
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| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293015348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645792015 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2151 E. MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293071441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645792015 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2012 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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| AuthorizedOfficialLastName: | HAVILAND | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8645792015 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 775 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | D07758 | 05 | SC | MEDICAID |