Provider Demographics
NPI:1124115506
Name:THOMAS, KENNETH L (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:THOMAS
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 1:1372 W ROBINHOOD DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5513
Mailing Address - Country:US
Mailing Address - Phone:209-477-4414
Mailing Address - Fax:209-477-0159
Practice Address - Street 1:1372 W ROBINHOOD DR
Practice Address - Street 2:SUITE D
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5513
Practice Address - Country:US
Practice Address - Phone:209-477-4414
Practice Address - Fax:209-477-0159
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5472T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0054720Medicaid
CASD0054720Medicaid
0504530001Medicare NSC
SD0054720Medicare ID - Type Unspecified