Healthcare Provider Details

I. General information

NPI: 1295764934
Provider Name (Legal Business Name): STEVEN PAUL THIBON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 01/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N PARK DR
KEOKUK IA
52632-2200
US

IV. Provider business mailing address

57606 CONNOR RD
CALIFORNIA MO
65018-5614
US

V. Phone/Fax

Practice location:
  • Phone: 319-524-1080
  • Fax:
Mailing address:
  • Phone: 573-619-1088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03130
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: