Provider Demographics
NPI:1821054560
Name:THOMPSON, SHELLY HOLDER (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:HOLDER
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 KING STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-2410
Mailing Address - Country:US
Mailing Address - Phone:904-760-4904
Mailing Address - Fax:904-760-4250
Practice Address - Street 1:120 KING ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-2410
Practice Address - Country:US
Practice Address - Phone:904-760-4904
Practice Address - Fax:904-760-4250
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0038917208000000X
FLME38917208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066208900Medicaid
FL0662089-00Medicaid
FL066208900Medicaid
FLCP699ZMedicare PIN
FL15685Medicare PIN