Provider Demographics
NPI:1306949284
Name:THOMPSON, MARY LU (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LU
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3123 VASSAR DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-3439
Mailing Address - Country:US
Mailing Address - Phone:706-736-9664
Mailing Address - Fax:
Practice Address - Street 1:3830 WASHINGTON RD
Practice Address - Street 2:SUITE 17
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-5064
Practice Address - Country:US
Practice Address - Phone:706-922-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA35777207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAC73697Medicare UPIN
GAC73697Medicare UPIN