Provider Demographics
NPI:1477545762
Name:THOMPSON, GARY A (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
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 1:3406 BROADWAY BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111-2404
Mailing Address - Country:US
Mailing Address - Phone:816-756-5839
Mailing Address - Fax:816-756-5874
Practice Address - Street 1:3406 BROADWAY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2404
Practice Address - Country:US
Practice Address - Phone:816-756-5839
Practice Address - Fax:816-756-5874
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36683207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100357610AMedicaid
MO208229112Medicaid
MOP00371149OtherRAILROAD MEDICARE
KS100357610BMedicaid
E23391Medicare UPIN
KS100357610BMedicaid