Provider Demographics
NPI:1205831997
Name:THOMPSON, FREDERICK L (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:L
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 1:900 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-3210
Mailing Address - Country:US
Mailing Address - Phone:417-667-6015
Mailing Address - Fax:417-667-3007
Practice Address - Street 1:900 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3210
Practice Address - Country:US
Practice Address - Phone:417-667-6015
Practice Address - Fax:417-667-3007
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8308207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH753878Medicare ID - Type Unspecified
MOC50341Medicare UPIN