Provider Demographics
NPI:1770376931
Name:THOMAS, JACK OWEN (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:OWEN
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 SINALOA RD
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-5428
Mailing Address - Country:US
Mailing Address - Phone:805-791-7350
Mailing Address - Fax:
Practice Address - Street 1:1969 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3765
Practice Address - Country:US
Practice Address - Phone:312-864-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.085447207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology