Healthcare Provider Details

I. General information

NPI: 1053423640
Provider Name (Legal Business Name): KIRK THOMPSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 GEORGIANA ST
PORT ANGELES WA
98362-3511
US

IV. Provider business mailing address

811 GEORGIANA ST
PORT ANGELES WA
98362-3511
US

V. Phone/Fax

Practice location:
  • Phone: 360-452-7661
  • Fax: 360-417-0254
Mailing address:
  • Phone: 360-452-7661
  • Fax: 360-417-0254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1267TX
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1267TX
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number1267TX
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1267TX
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: