Provider Demographics
NPI:1871512731
Name:THEIS, KIMBERLY S (OD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:S
Last Name:THEIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:S
Other - Last Name:SPANGLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4240 SCIOTO PKWY
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8075
Mailing Address - Country:US
Mailing Address - Phone:614-517-7167
Mailing Address - Fax:
Practice Address - Street 1:3998 POWELL RD
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-7662
Practice Address - Country:US
Practice Address - Phone:614-336-3727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13027152W00000X
NE1295152W00000X
OH5660152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHV10694Medicare UPIN