Provider Demographics
NPI:1669535761
Name:THOMAS, ANGELA M (OD)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:M
Last Name:THOMAS
Suffix:
Gender:F
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:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:KOSCIOSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090
Mailing Address - Country:US
Mailing Address - Phone:662-289-1067
Mailing Address - Fax:662-289-1058
Practice Address - Street 1:59 VETERANS MEMORIAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090
Practice Address - Country:US
Practice Address - Phone:662-289-1067
Practice Address - Fax:662-289-1058
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS562152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087013Medicaid
P00065350OtherRR MEDICARE
MS00087013Medicaid
MS410000044Medicare PIN