=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083675219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS GLENN STINE I O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2006
-----------------------------------------------------
Last Update Date | 09/03/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3575 MAPLE AVE SEARS OPTICAL
-----------------------------------------------------
City | ZANESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43701-7019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-452-1716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 884 HILLGAIL CIR SW
-----------------------------------------------------
City | PATASKALA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43062-9141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-964-2611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 3995T973
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------