Provider Demographics
NPI:1780319954
Name:THORP, BLAINE MICHAEL (OD)
Entity type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:MICHAEL
Last Name:THORP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1236 QUIET HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:IN
Mailing Address - Zip Code:46737-7500
Mailing Address - Country:US
Mailing Address - Phone:419-356-3210
Mailing Address - Fax:
Practice Address - Street 1:712 CAMERON WOODS DR
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-8816
Practice Address - Country:US
Practice Address - Phone:260-665-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004347A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist