Provider Demographics
NPI:1548258767
Name:BLUE, THOMAS DEAN
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:DEAN
Last Name:BLUE
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:DEAN
Other - Last Name:BLUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:4650 SE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-3008
Mailing Address - Country:US
Mailing Address - Phone:405-677-8831
Mailing Address - Fax:405-677-8865
Practice Address - Street 1:4650 SE 15TH ST
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3008
Practice Address - Country:US
Practice Address - Phone:405-677-8831
Practice Address - Fax:405-677-8865
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK863152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0292840001Medicare NSC
OK243611001Medicare PIN
OK$$$$$$$$$Medicare PIN
OKT40363Medicare UPIN