Provider Demographics
NPI:1063820306
Name:THOMPSON, PHILLIP (OD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:THOMPSON
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 1:11827 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-1314
Mailing Address - Country:US
Mailing Address - Phone:724-557-4171
Mailing Address - Fax:
Practice Address - Street 1:11827 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-1314
Practice Address - Country:US
Practice Address - Phone:913-663-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014020365152W00000X
KS1992152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist