Provider Demographics
NPI:1063521136
Name:THOMPSON, PETER JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JEFFREY
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6493
Mailing Address - Country:US
Mailing Address - Phone:208-529-5252
Mailing Address - Fax:208-529-4434
Practice Address - Street 1:1995 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6493
Practice Address - Country:US
Practice Address - Phone:208-529-5252
Practice Address - Fax:208-529-4434
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1117847Medicare ID - Type Unspecified
IDD72144Medicare UPIN