Provider Demographics
NPI:1770774663
Name:BOURDON, THOMAS (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:BOURDON
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 MCCRACKEN ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-3670
Mailing Address - Country:US
Mailing Address - Phone:231-755-2291
Mailing Address - Fax:231-755-2293
Practice Address - Street 1:3375 MCCRACKEN ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-3670
Practice Address - Country:US
Practice Address - Phone:231-755-2291
Practice Address - Fax:231-755-2293
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0817390001Medicare UPIN
MI0817390001Medicare PIN