Healthcare Provider Details

I. General information

NPI: 1265496871
Provider Name (Legal Business Name): THOMAS I PORTER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S SPRING AVE
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-5200
  • Fax: 314-977-3495
Mailing address:
  • Phone: 314-977-4010
  • Fax: 314-977-3495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberT02178
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: