Provider Demographics
NPI:1174695100
Name:THIBAULT, SETH ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:SETH
Middle Name:ALAN
Last Name:THIBAULT
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:PO BOX 1024
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-1024
Mailing Address - Country:US
Mailing Address - Phone:620-672-5934
Mailing Address - Fax:620-672-3550
Practice Address - Street 1:216 S OAK ST
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-2721
Practice Address - Country:US
Practice Address - Phone:620-672-5934
Practice Address - Fax:620-672-3550
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00152892OtherRAILROAD MEDICARE
KS200266640AMedicaid
KS650995Medicare ID - Type Unspecified
KS200266640AMedicaid