Provider Demographics
NPI:1396381539
Name:OMAR THOMPSON ORAL THOMPSON
Entity Type:Organization
Organization Name:OMAR THOMPSON ORAL THOMPSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTOR
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-785-9459
Mailing Address - Street 1:20 GOODALE RD APT 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02126-1788
Mailing Address - Country:US
Mailing Address - Phone:617-785-9459
Mailing Address - Fax:
Practice Address - Street 1:20 GOODALE RD APT 2
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02126-1788
Practice Address - Country:US
Practice Address - Phone:617-785-9459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health