Healthcare Provider Details

I. General information

NPI: 1417934951
Provider Name (Legal Business Name): THOMAS GEORGE CROFFEAD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3531 MARY ADER AVE SUITE B
CHARLESTON SC
29414-5896
US

IV. Provider business mailing address

3531 MARY ADER AVE SUITE B
CHARLESTON SC
29414-5896
US

V. Phone/Fax

Practice location:
  • Phone: 843-577-2047
  • Fax: 843-577-0640
Mailing address:
  • Phone: 843-577-2047
  • Fax: 843-577-0640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number515
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: