Provider Demographics
NPI:1720082415
Name:THORSEN, DARREN L (OD)
Entity type:Individual
Prefix:DR
First Name:DARREN
Middle Name:L
Last Name:THORSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 PACIFIC AVE S
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:WA
Mailing Address - Zip Code:98631-3400
Mailing Address - Country:US
Mailing Address - Phone:360-642-3214
Mailing Address - Fax:360-642-5333
Practice Address - Street 1:1703 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631-3400
Practice Address - Country:US
Practice Address - Phone:360-642-3214
Practice Address - Fax:360-642-5333
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3069TX152W00000X
OR2483T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR046289Medicaid
WA2022549Medicaid
OR046289Medicaid
WAG8803207Medicare ID - Type Unspecified
ORR119202Medicare ID - Type Unspecified