Provider Demographics
NPI:1063759249
Name:THOMPSON, DEMON RANDOLPH (CPED)
Entity type:Individual
Prefix:
First Name:DEMON
Middle Name:RANDOLPH
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 E 68TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4709
Mailing Address - Country:US
Mailing Address - Phone:912-355-4557
Mailing Address - Fax:912-355-3186
Practice Address - Street 1:803 E 68TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4709
Practice Address - Country:US
Practice Address - Phone:912-355-4557
Practice Address - Fax:912-355-3186
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACPED3471247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other