Provider Demographics
NPI:1407855596
Name:THOMPSON, BRUCE ERWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ERWIN
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 1:6105 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2225
Mailing Address - Country:US
Mailing Address - Phone:510-658-7660
Mailing Address - Fax:510-658-5138
Practice Address - Street 1:6105 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94608-2225
Practice Address - Country:US
Practice Address - Phone:510-658-7660
Practice Address - Fax:510-658-5138
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2008-11-10
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
CAC31211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
942162760OtherTIN
CA00C312110Medicare PIN
CA00C312110Medicare ID - Type UnspecifiedMEDI-CAL PIN
942162760OtherTIN