Basic Information
| Provider Information | |||||||||
| NPI: | 1679553234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | RANDI | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | STE. 2222 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 UNIVERSITY BLVD NE | ||||||||
| Address2: | STE. C | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871021724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722553 | ||||||||
| FaxNumber: | 5059254785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 07/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | 465 | NM | Y | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
ID Information
| ID | Type | State | Issuer | Description | Q4711 | 05 | NM | MEDICAID |