1376515452 NPI number — DR. JESS LEE THOMPSON III M.D.

Table of content: DR. JESS LEE THOMPSON III M.D. (NPI 1376515452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376515452 NPI number — DR. JESS LEE THOMPSON III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
JESS
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
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:
THOMPSON
Provider Other First Name:
JESS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1376515452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10880
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86304-0880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-759-5874
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 CHILDRENS AVE
Provider Second Line Business Practice Location Address:
STE 2E
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73104-4637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-271-5789
Provider Business Practice Location Address Fax Number:
405-271-1643
Provider Enumeration Date:
02/03/2006

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: 208G00000X , with the licence number:  44766 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: 31236 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200528410A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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