Provider Demographics
NPI:1023185386
Name:THOMPSON, KEITH M (OD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:M
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1700 TAMIAMI TRL UNIT G7A
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-1063
Mailing Address - Country:US
Mailing Address - Phone:941-468-4766
Mailing Address - Fax:
Practice Address - Street 1:375 KINGS HWY
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33983-5222
Practice Address - Country:US
Practice Address - Phone:941-625-5359
Practice Address - Fax:941-625-5420
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2418152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410044567OtherRR
T59274Medicare UPIN
410044567OtherRR