Provider Demographics
NPI:1164776282
Name:THOREBY, SEAN (OD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:THOREBY
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 1:10002 SE 240TH ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-4839
Mailing Address - Country:US
Mailing Address - Phone:253-852-2020
Mailing Address - Fax:253-854-2020
Practice Address - Street 1:10002 SE 240TH ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-4839
Practice Address - Country:US
Practice Address - Phone:253-852-2020
Practice Address - Fax:253-854-2020
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60570238152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8944042OtherMEDICARE PTAN