Provider Demographics
NPI:1306925250
Name:THOMPSON, JOAN B (MD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:B
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 CASH LN
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-5334
Mailing Address - Country:US
Mailing Address - Phone:208-983-0160
Mailing Address - Fax:
Practice Address - Street 1:169 CASH LN
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-5334
Practice Address - Country:US
Practice Address - Phone:208-983-0160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6339207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1128074Medicare ID - Type Unspecified
IDF66172Medicare UPIN