Provider Demographics
NPI:1942627476
Name:THOMPSON, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
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 1:1011 SAN RAFAEL ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5348
Mailing Address - Country:US
Mailing Address - Phone:904-540-5277
Mailing Address - Fax:
Practice Address - Street 1:5530-1 FLORIDA MINING BLVD. S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257
Practice Address - Country:US
Practice Address - Phone:904-826-5001
Practice Address - Fax:904-661-0021
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-21
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine