Provider Demographics
NPI:1487617692
Name:THOMPSON, GAUTHAMA (DC, CCSP)
Entity type:Individual
Prefix:DR
First Name:GAUTHAMA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 HANCOCK ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RUMFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04276-1937
Mailing Address - Country:US
Mailing Address - Phone:207-364-7931
Mailing Address - Fax:207-364-3644
Practice Address - Street 1:344 HANCOCK ST
Practice Address - Street 2:SUITE 1
Practice Address - City:RUMFORD
Practice Address - State:ME
Practice Address - Zip Code:04276-1937
Practice Address - Country:US
Practice Address - Phone:207-364-7931
Practice Address - Fax:207-364-3644
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1066111NS0005X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME6632Medicare PIN