Provider Demographics
NPI:1609865120
Name:THOMPSON, CHAD JUSTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:JUSTIN
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 1:214 N MILL ST
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:KS
Mailing Address - Zip Code:67420-2346
Mailing Address - Country:US
Mailing Address - Phone:785-738-3816
Mailing Address - Fax:785-738-4320
Practice Address - Street 1:214 N MILL ST
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:KS
Practice Address - Zip Code:67420-2346
Practice Address - Country:US
Practice Address - Phone:785-738-3816
Practice Address - Fax:785-738-4320
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100355410DMedicaid
KS651095Medicare ID - Type Unspecified