Provider Demographics
NPI:1124143987
Name:WOYTTA, THOMAS (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:WOYTTA
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 1:1100 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-2112
Mailing Address - Country:US
Mailing Address - Phone:810-364-1334
Mailing Address - Fax:810-364-1075
Practice Address - Street 1:1100 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2112
Practice Address - Country:US
Practice Address - Phone:810-364-1334
Practice Address - Fax:810-364-1075
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3462930Medicaid
MI1238960001Medicare NSC
MIU30656Medicare UPIN
MIOM59270Medicare PIN