Provider Demographics
NPI:1114005592
Name:THOMPSON YOUNG, DIANA KIM (OD)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:KIM
Last Name:THOMPSON YOUNG
Suffix:
Gender:F
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-0549
Mailing Address - Country:US
Mailing Address - Phone:360-683-3389
Mailing Address - Fax:360-683-7069
Practice Address - Street 1:128 E WASHINGTON
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382
Practice Address - Country:US
Practice Address - Phone:360-683-3389
Practice Address - Fax:360-683-7069
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003537152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA133203OtherLABOR & INDUSTRIES
WA2023174Medicaid
U77958Medicare UPIN
WA2023174Medicaid