Healthcare Provider Details

I. General information

NPI: 1578539235
Provider Name (Legal Business Name): THOMAS CARTON CHURCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 YACHT CLUB DR NE
FT WALTON BEACH FL
32547-4473
US

IV. Provider business mailing address

51 YACHT CLUB DR NE
FT WALTON BEACH FL
32548-4473
US

V. Phone/Fax

Practice location:
  • Phone: 850-244-1157
  • Fax:
Mailing address:
  • Phone: 850-244-1157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME0016848
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: