Provider Demographics
NPI:1164472676
Name:THOMPSON, TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
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:PO BOX 4356
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4356
Mailing Address - Country:US
Mailing Address - Phone:361-334-5130
Mailing Address - Fax:361-334-5284
Practice Address - Street 1:5701 S PADRE ISLAND DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-3903
Practice Address - Country:US
Practice Address - Phone:361-334-5130
Practice Address - Fax:361-334-5284
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL85822085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1677080-02Medicaid
TX1677080-01Medicaid
TX8C1000Medicare PIN
TX8C0427Medicare PIN
TX1677080-01Medicaid