Provider Demographics
NPI:1710111224
Name:THOMPSON, KYLE G (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:G
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 1:2100 PROVIDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4951
Mailing Address - Country:US
Mailing Address - Phone:208-529-6600
Mailing Address - Fax:208-529-6602
Practice Address - Street 1:2100 PROVIDENCE WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6236
Practice Address - Country:US
Practice Address - Phone:208-529-6600
Practice Address - Fax:208-529-6602
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12830207W00000X
IDM12830207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1710111224Medicaid
ID1710111224Medicaid
ID20000131Medicare PIN