Provider Demographics
NPI:1518964220
Name:THOMPSON, DAVID SHANNON (CPO)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:SHANNON
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 ALTAMA AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-3629
Mailing Address - Country:US
Mailing Address - Phone:912-261-8117
Mailing Address - Fax:912-261-8301
Practice Address - Street 1:3501 ALTAMA AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-3629
Practice Address - Country:US
Practice Address - Phone:912-261-8117
Practice Address - Fax:912-261-8301
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA01521222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00742871AMedicaid
GA1181630001Medicare NSC