1154769958 NPI number — DR. IAN ABBAN THOMPSON M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154769958 NPI number — DR. IAN ABBAN THOMPSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
IAN
Provider Middle Name:
ABBAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154769958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8801 HORIZON BLVD NE STE 360
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87113-1563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-828-4923
Provider Business Mailing Address Fax Number:
505-213-0103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4411 THE 25 WAY NE STE 325
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87109-5853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-823-4411
Provider Business Practice Location Address Fax Number:
505-343-6085
Provider Enumeration Date:
06/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD2021-0639 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 54721351 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 147790 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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