Provider Demographics
NPI:1336506005
Name:THOMPSON, HEATHER (DOM)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 CRESSWELL RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21225-3812
Mailing Address - Country:US
Mailing Address - Phone:410-914-7198
Mailing Address - Fax:
Practice Address - Street 1:1439 E FORT AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-5575
Practice Address - Country:US
Practice Address - Phone:410-914-7198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02196171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCE89-0001OtherCAREFIRST BLUE CROSS BLUE SHIELD