Provider Demographics
NPI:1528072683
Name:HIXSON, THOMAS MARK (OD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MARK
Last Name:HIXSON
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 1:8007 LA MESA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-6434
Mailing Address - Country:US
Mailing Address - Phone:619-466-5665
Mailing Address - Fax:619-466-5688
Practice Address - Street 1:8007 LA MESA BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-6434
Practice Address - Country:US
Practice Address - Phone:619-466-5665
Practice Address - Fax:619-466-5688
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7490T152W00000X, 152WC0802X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD00749009Medicaid
CAWY049Medicare PIN
CAWOP749OEMedicare PIN
CAU28581Medicare UPIN