Provider Demographics
NPI:1386777860
Name:BLAN, TOMMIE L JR
Entity type:Individual
Prefix:MR
First Name:TOMMIE
Middle Name:L
Last Name:BLAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68112-1808
Mailing Address - Country:US
Mailing Address - Phone:402-451-1717
Mailing Address - Fax:402-451-3469
Practice Address - Street 1:8616 N 30TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68112-1808
Practice Address - Country:US
Practice Address - Phone:402-451-1717
Practice Address - Fax:402-451-3469
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025369100Medicaid
NE017542Medicaid