Provider Demographics
NPI:1427123405
Name:THOMAS, JAMES DERRYL (OD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DERRYL
Last Name:THOMAS
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 1:198 SW BROAD ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-1101
Mailing Address - Country:US
Mailing Address - Phone:912-530-6000
Mailing Address - Fax:912-530-6044
Practice Address - Street 1:198 SW BROAD ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-1101
Practice Address - Country:US
Practice Address - Phone:912-530-6000
Practice Address - Fax:912-530-6044
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1256152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00461876BMedicaid
GA00461876DMedicaid
GA410026823Medicare ID - Type UnspecifiedRR MEDICARE #
GA00461876BMedicaid
GAU17400Medicare UPIN
GA00461876DMedicaid
GA41ZCBQWMedicare PIN