Provider Demographics
NPI:1447470992
Name:BLAIR JR., THOMAS (LDO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BLAIR JR.
Suffix:
Gender:M
Credentials:LDO
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 574
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-0574
Mailing Address - Country:US
Mailing Address - Phone:770-348-9955
Mailing Address - Fax:404-523-8012
Practice Address - Street 1:862 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30314-3642
Practice Address - Country:US
Practice Address - Phone:770-348-9955
Practice Address - Fax:404-523-8012
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO#748156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician