Provider Demographics
NPI:1760478580
Name:THOMPSON, BARRY LANE (MD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:LANE
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2060 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4177
Mailing Address - Country:US
Mailing Address - Phone:706-738-4442
Mailing Address - Fax:770-381-6451
Practice Address - Street 1:2060 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4177
Practice Address - Country:US
Practice Address - Phone:706-738-4442
Practice Address - Fax:770-381-6451
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA013094207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000130666BMedicaid
SCG13094Medicaid
GA406072004OtherRAILROAD MEDICARE
GA033800OtherBLUE CROSS/BLUE SHIELD GA
GA4114157OtherAETNA
GA265295OtherFIRST HEALTH PLAN
GA4114157OtherAETNA
GAD41234Medicare UPIN