Provider Demographics
NPI:1386890812
Name:THOMPSON, MISTY DANIELLE (DO)
Entity type:Individual
Prefix:DR
First Name:MISTY
Middle Name:DANIELLE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:210 BLACK GOLD BLVD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-2620
Mailing Address - Country:US
Mailing Address - Phone:606-439-0326
Mailing Address - Fax:606-439-0475
Practice Address - Street 1:1019 CUMBERLAND FALLS HWY STE D141
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2796
Practice Address - Country:US
Practice Address - Phone:606-528-5527
Practice Address - Fax:606-526-9687
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY655207V00000X
KY3528207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100210760Medicaid