Provider Demographics
NPI:1790146843
Name:THOMPSON, MARK (LAC, PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LAC, PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 W 57TH ST FL 10
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2220
Mailing Address - Country:US
Mailing Address - Phone:212-974-7240
Mailing Address - Fax:
Practice Address - Street 1:119 W 57TH ST STE 600
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2305
Practice Address - Country:US
Practice Address - Phone:212-974-7240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011079225100000X
NY001044171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist