Provider Demographics
NPI:1730526716
Name:THOMPSON, TRAVIS LEE (OD)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:LEE
Last Name:THOMPSON
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 1:10904 SPRING BLUFF WAY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-1793
Mailing Address - Country:US
Mailing Address - Phone:865-246-1500
Mailing Address - Fax:865-245-4522
Practice Address - Street 1:10904 SPRING BLUFF WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37932-1793
Practice Address - Country:US
Practice Address - Phone:865-246-1500
Practice Address - Fax:865-245-4522
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002234152W00000X
TN3122152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I415320OtherMEDICARE PTAN
TNQ006781Medicaid