Provider Demographics
NPI:1033128848
Name:THOMASON, FRED GODWIN (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:GODWIN
Last Name:THOMASON
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 1:5515 SHELBY OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-7316
Mailing Address - Country:US
Mailing Address - Phone:901-252-7718
Mailing Address - Fax:901-252-7680
Practice Address - Street 1:5515 SHELBY OAKS DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-7316
Practice Address - Country:US
Practice Address - Phone:901-252-7718
Practice Address - Fax:901-252-7680
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN123242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3183887Medicaid
MS0070712Medicaid
MS0011150Medicaid
TN3183887Medicaid
MS0011150Medicaid