Healthcare Provider Details

I. General information

NPI: 1629871173
Provider Name (Legal Business Name): JONATHAN THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8447 RIVERSIDE PKWY
BRYAN TX
77807
US

IV. Provider business mailing address

8447 RIVERSIDE PKWY
BRYAN TX
77807
US

V. Phone/Fax

Practice location:
  • Phone: 979-436-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberBP10097664
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: