Provider Demographics
NPI:1538136361
Name:THOMPSON, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-1840
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:621 MEMORIAL DR STE 502
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1075
Practice Address - Country:US
Practice Address - Phone:574-647-5875
Practice Address - Fax:574-647-5787
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2023-04-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01063692A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200879410Medicaid
IN264180CCMedicare PIN