Provider Demographics
NPI:1366132284
Name:WIGHT, THOMAS J (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:WIGHT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:779 VIA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-1574
Mailing Address - Country:US
Mailing Address - Phone:585-545-9504
Mailing Address - Fax:
Practice Address - Street 1:1312 MANATEE AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1358
Practice Address - Country:US
Practice Address - Phone:941-708-8700
Practice Address - Fax:941-708-8706
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOPC6342152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program