Provider Demographics
NPI:1558361717
Name:THOMPSON, BRYAN T (DPM)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:T
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 E POLSTON AVE
Mailing Address - Street 2:STE A
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854
Mailing Address - Country:US
Mailing Address - Phone:208-777-9794
Mailing Address - Fax:208-777-9523
Practice Address - Street 1:1590 E POLSTON AVE
Practice Address - Street 2:STE A
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854
Practice Address - Country:US
Practice Address - Phone:208-777-9794
Practice Address - Fax:208-777-9523
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-173213ES0103X
IDP173213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP9293OtherBLUE CROSS
ID807068300Medicaid
IDI0007985456OtherAETNA
ID000010149213OtherBLUE SHIELD OF IDAHO
ID000010149213OtherBLUE SHIELD OF IDAHO
IDP9293OtherBLUE CROSS