Provider Demographics
NPI:1669495321
Name:THOMPSON, SAMUEL TYRONE (PT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:TYRONE
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:TYRONE
Other - Middle Name:S
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:20195 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3850
Mailing Address - Country:US
Mailing Address - Phone:352-754-4500
Mailing Address - Fax:352-754-9343
Practice Address - Street 1:20195 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3850
Practice Address - Country:US
Practice Address - Phone:352-754-4500
Practice Address - Fax:352-754-9343
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18754225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006746600Medicaid
FL006746600Medicaid