Provider Demographics
NPI:1104902121
Name:THOMPSON, OWEN R
Entity type:Individual
Prefix:
First Name:OWEN
Middle Name:R
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 S CASCADE ST
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2913
Mailing Address - Country:US
Mailing Address - Phone:218-736-8000
Mailing Address - Fax:218-739-6718
Practice Address - Street 1:209 2ND ST SE
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56514-0279
Practice Address - Country:US
Practice Address - Phone:218-354-2111
Practice Address - Fax:218-354-2114
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25582207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN243809Medicare Oscar/Certification