Provider Demographics
NPI:1083635676
Name:BRELAGE, THOMAS G (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:BRELAGE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 W JOHN FITCH AVE
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1115
Mailing Address - Country:US
Mailing Address - Phone:502-348-1107
Mailing Address - Fax:
Practice Address - Street 1:206 W JOHN FITCH AVE
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1115
Practice Address - Country:US
Practice Address - Phone:502-348-1107
Practice Address - Fax:502-348-0294
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY934DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77009348Medicaid
KY911185OtherBLOCK VISION
KY1103277OtherPASSPORT
KY000000050702OtherANTHEM
KY911185OtherBLOCK VISION
T54721Medicare UPIN
KY0641580001Medicare NSC
KY1103277OtherPASSPORT