Provider Demographics
NPI:1306068903
Name:JOHN CARLOS THOMPSON MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JOHN CARLOS THOMPSON MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN,OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-593-1212
Mailing Address - Street 1:1625 E MAIN STREET
Mailing Address - Street 2:STE 201
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021
Mailing Address - Country:US
Mailing Address - Phone:619-593-1212
Mailing Address - Fax:
Practice Address - Street 1:1625 E MAIN STREET
Practice Address - Street 2:STE 201
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021
Practice Address - Country:US
Practice Address - Phone:619-593-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83902174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G839020Medicaid
CABT4703270OtherDEA
CABT4703270OtherDEA
CA00G839020Medicaid