Provider Demographics
NPI:1487646030
Name:THOMPSON, MARK EDMUND (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDMUND
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 W US HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-8341
Mailing Address - Country:US
Mailing Address - Phone:352-755-0601
Mailing Address - Fax:352-755-0602
Practice Address - Street 1:4520 W US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-8341
Practice Address - Country:US
Practice Address - Phone:352-755-0601
Practice Address - Fax:352-755-0602
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS101942085R0001X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL310302OtherAVMED
FL279300800Medicaid
OH0825156Medicaid
FLPTAN AG644EOtherLINKED TO GROUP PTAN IE881A EFFECTIVE 08/01/2015
FL02484OtherBLUE CROSS BLUE SHIELD
FL279300800Medicaid
FLAG644VMedicare PIN
FLPTAN AG644EOtherLINKED TO GROUP PTAN IE881A EFFECTIVE 08/01/2015
FL310302OtherAVMED
FLAG644UMedicare PIN
FLAG644ZMedicare PIN
FLAG644FMedicare PIN
FLAG644RMedicare PIN
FLAG644XMedicare PIN
FL02484OtherBLUE CROSS BLUE SHIELD
FLAG644PMedicare PIN
FLAG644TMedicare PIN
FLAG644GMedicare PIN
FLAG644QMedicare PIN
FLAG644WMedicare PIN
FLAG644YMedicare PIN
C29916Medicare UPIN
FLAG644LMedicare PIN