Provider Demographics
NPI:1336556893
Name:HALL, TOM LAVERN II (OD)
Entity type:Individual
Prefix:DR
First Name:TOM
Middle Name:LAVERN
Last Name:HALL
Suffix:II
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:136 E GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-5136
Mailing Address - Country:US
Mailing Address - Phone:517-223-9988
Mailing Address - Fax:517-223-9071
Practice Address - Street 1:136 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FOWLERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48836
Practice Address - Country:US
Practice Address - Phone:517-223-9988
Practice Address - Fax:517-223-9071
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4901004859152WC0802X, 152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1336556893Medicaid