Provider Demographics
NPI:1033189568
Name:THOMPSON, DONNA RUTH (MD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:RUTH
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NORTH WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5105
Mailing Address - Country:US
Mailing Address - Phone:909-883-8611
Mailing Address - Fax:909-886-1798
Practice Address - Street 1:1700 NORTH WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5105
Practice Address - Country:US
Practice Address - Phone:909-883-8611
Practice Address - Fax:909-886-1798
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G671440Medicaid
CA00G671440Medicaid
F09941Medicare UPIN