Provider Demographics
NPI:1932175015
Name:THOMPSON, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5178 MILANO ST
Mailing Address - Street 2:
Mailing Address - City:AVE MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34142-9548
Mailing Address - Country:US
Mailing Address - Phone:860-460-7195
Mailing Address - Fax:860-460-7195
Practice Address - Street 1:5178 MILANO ST
Practice Address - Street 2:
Practice Address - City:AVE MARIA
Practice Address - State:FL
Practice Address - Zip Code:34142-9548
Practice Address - Country:US
Practice Address - Phone:860-460-7195
Practice Address - Fax:860-460-7195
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039780208000000X
FLME137399208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001397802Medicaid