Provider Demographics
NPI:1598125775
Name:THOMPSON, MICHAEL (LO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 BUCKLAND HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-8755
Mailing Address - Country:US
Mailing Address - Phone:860-644-1203
Mailing Address - Fax:860-644-2936
Practice Address - Street 1:420 BUCKLAND HILLS DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-8755
Practice Address - Country:US
Practice Address - Phone:860-644-1203
Practice Address - Fax:860-644-2936
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1489156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician