Provider Demographics
NPI:1639480759
Name:THOMPSON, CARLIE KENNEDY (MD)
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:KENNEDY
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARLIE
Other - Middle Name:REBECCA
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:191 S BUENA VISTA ST STE 415
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4541
Practice Address - Country:US
Practice Address - Phone:818-333-2555
Practice Address - Fax:818-333-2559
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127831208600000X
CAA1278312086X0206X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery