Provider Demographics
NPI:1104810589
Name:THOMPSON, THOMAS REECE (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:REECE
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:PO BOX 1296
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38025-1296
Mailing Address - Country:US
Mailing Address - Phone:731-285-2346
Mailing Address - Fax:731-285-4717
Practice Address - Street 1:400 E TICKLE ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-285-2346
Practice Address - Fax:731-285-4717
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD71432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3169037Medicaid
TN3169037Medicare ID - Type Unspecified
B03318Medicare UPIN