Provider Demographics
NPI:1972612919
Name:THOMPSON, DAVID E (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
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 1:4070 LAKE DR SE
Mailing Address - Street 2:STE 103
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8294
Mailing Address - Country:US
Mailing Address - Phone:616-949-4340
Mailing Address - Fax:616-949-4341
Practice Address - Street 1:4070 LAKE DR SE
Practice Address - Street 2:STE 103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8294
Practice Address - Country:US
Practice Address - Phone:616-949-4340
Practice Address - Fax:616-949-4341
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055697208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2648202Medicaid
340003125OtherRAILROAD MEDICARE
MI340D160430OtherBCBSM
0D16043004Medicare ID - Type Unspecified
MI2648202Medicaid
MIP32930288Medicare PIN