Provider Demographics
NPI:1619938412
Name:THOMPSON, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
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:PO BOX 708850
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-8850
Mailing Address - Country:US
Mailing Address - Phone:866-869-2397
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:1111 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6241
Practice Address - Country:US
Practice Address - Phone:541-732-5545
Practice Address - Fax:541-732-5548
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19883207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR858464010OtherBCBS-SPRINGFIELD
ORP00061232OtherRR MEDICARE
ORR134117OtherMEDICARE-TYPE UNSPECIFIED
OR044797Medicaid
OR838334015OtherBCBS-ROSEBURG
AZ210965Medicaid
OR8584463012OtherBCBS-MEDFORD
OR858464010OtherBCBS-SPRINGFIELD
AZ116799Medicare PIN
OR044797Medicaid