Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | TO3423 | MO |
NPI | 1003998907 |
---|---|
Provider Name | Jeff Thompson |
First Address | O Fallon, MO 63368-7192 |
Second Address | St. Louis, MO 63126 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0 | NA (01) | MO |