Provider Demographics
NPI:1215917323
Name:WILLMON, THOMAS GREGORY (OD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GREGORY
Last Name:WILLMON
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:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-0700
Mailing Address - Country:US
Mailing Address - Phone:575-763-5522
Mailing Address - Fax:575-763-4722
Practice Address - Street 1:1217 PILE ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-5944
Practice Address - Country:US
Practice Address - Phone:575-763-5522
Practice Address - Fax:575-763-4722
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOP2291152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00P511OtherBCBS
NMP0532Medicaid
NMU02949Medicare UPIN
NM0173070001Medicare Oscar/Certification
NMP0532Medicaid
NM0173070001Medicare NSC