Provider Demographics
NPI:1235181561
Name:THOMPSON, KENT W (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:W
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 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-340-3911
Mailing Address - Fax:760-773-1574
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-340-3911
Practice Address - Fax:760-773-1574
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG516062085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G516060Medicaid
CA00G516060OtherBLUE SHIELD PIN
CAWG51606GMedicare PIN
CAWG51606FMedicare PIN
CAWG51606HMedicare PIN
CAWG51606DMedicare PIN
CA00G516060OtherBLUE SHIELD PIN