Healthcare Provider Details

I. General information

NPI: 1881859734
Provider Name (Legal Business Name): MICHAEL ANTHONY TOMMOLINO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MDG / RAF LAKENHEATH UNIT 5115
APO AE
09461
US

IV. Provider business mailing address

7321 BALMER ST BLDG 570
HILL AFB UT
84056-5012
US

V. Phone/Fax

Practice location:
  • Phone: 314-226-8205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004489
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: