Provider Demographics
NPI:1821183104
Name:THOMPSON, MASON P (MD)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:P
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 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2650
Mailing Address - Country:US
Mailing Address - Phone:706-724-6100
Mailing Address - Fax:706-722-5187
Practice Address - Street 1:1120 15TH STREET
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912
Practice Address - Country:US
Practice Address - Phone:706-721-4588
Practice Address - Fax:706-721-7264
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC182100Medicaid
GA0001389279AMedicaid
GA0001389279AMedicaid
GA08DFZHMedicare ID - Type Unspecified