Provider Demographics
NPI:1174654669
Name:THOMPSON, JONATHAN NGOZI (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:NGOZI
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 1:55 WADE AVENUE
Mailing Address - Street 2:SPRING GROVE HOSPITAL CENTER
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228
Mailing Address - Country:US
Mailing Address - Phone:410-402-7486
Mailing Address - Fax:410-402-7094
Practice Address - Street 1:55 WADE AVENUE
Practice Address - Street 2:SPRING GROVE HOSPITAL CENTER
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228
Practice Address - Country:US
Practice Address - Phone:410-402-7486
Practice Address - Fax:410-402-7094
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0044044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F98307Medicare UPIN