Provider Demographics
NPI:1700910833
Name:STEVENS, THOMAS DALE (OD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:DALE
Last Name:STEVENS
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 1:1100 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-4030
Mailing Address - Country:US
Mailing Address - Phone:970-867-3046
Mailing Address - Fax:970-867-3046
Practice Address - Street 1:1100 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-4030
Practice Address - Country:US
Practice Address - Phone:970-867-3046
Practice Address - Fax:970-867-3046
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO910152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08009102Medicaid
CO08009102Medicaid
0747590001Medicare NSC