Provider Demographics
NPI:1851451850
Name:THOMPSON, MYRNA R (MD)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:R
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 1:3635 WHITEHILL DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-9713
Mailing Address - Country:US
Mailing Address - Phone:704-494-4147
Mailing Address - Fax:
Practice Address - Street 1:1981 J N PEASE PL STE 204
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4526
Practice Address - Country:US
Practice Address - Phone:704-510-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98-0101952084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89133KKMedicaid
NC89133KKMedicaid
NCBT6030415OtherDEA