Provider Demographics
NPI:1578747390
Name:THOMPSON, TIMOTHY LUKE (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:LUKE
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-3310
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1605 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3110
Practice Address - Country:US
Practice Address - Phone:601-579-3310
Practice Address - Fax:601-264-0231
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201055174400000X
MS21438207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03520851Medicaid
MS302I044563Medicare PIN