Provider Demographics
NPI:1427043454
Name:THOMPSON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:400 E 71ST ST
Mailing Address - Street 2:APT 11E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4808
Mailing Address - Country:US
Mailing Address - Phone:212-327-1958
Mailing Address - Fax:212-327-1956
Practice Address - Street 1:400 E 71ST ST
Practice Address - Street 2:APT 11E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4808
Practice Address - Country:US
Practice Address - Phone:212-327-1958
Practice Address - Fax:212-327-1956
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208307-1207T00000X
MI4301097635207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
18R251Medicare ID - Type Unspecified